Care Plan Template for Mr Ron Fraser: Ineffective Gaseous Exchange and Fluid Volume Overload

CARE PLAN TEMPLATE
Name of patient: Mr Ron Fraser Scenario number 3a
CARE PLAN ONE: ineffective gaseous exchange
List of related cues:
Elevated respiratory rate of 28
Decreased oxygen saturation of 89%
Crackles in all lungs on auscultation
Feeling lethargic and tired
Breathlessness during mobilisation
Pathophysiology :
Impaired kidney function leads to fluid overload in the body. This leads to overload and congestion in the
cardiovascular system. This is accompanied by heart failure. Left heart failure is one of the common
occurring which leads to pulmonary oedema which is the accumulation of fluid in the lung alveoli. It is
evidenced by crackles on auscultation. This thus reduces the available space for gaseous exchange and
impairs overall gaseous exchange (morel & firth, 2015) Due to ineffective gaseous exchange there is
decreased perfusion and therefore tissue hypoxia ensues as evidenced by low oxygen saturation of 89%
(normal 95-100%). Tissue hypoxia leads to anaerobic metabolism within the cells which leads to
accumulation of lactic acid. Anaerobic metabolism cannot continue for long due to the toxicity of lactic acid
on the cells. It then ceases and the cells become deprived of energy. The patient thus feels tired and
lethargic and is unable to carry out simple tasks thus activity intolerance such as slight walk because one
develops dyspnoeic. (morel & firth, 2015) The body will then develop counter measures. The respiratory rate
increases as compensatory mechanism. Mr Ron Fraser respiratory rate is elevated (28breathes per minute).
Normal rate should be 12- 20 breathes per minute in adults.(Copstead and Banasik, 2013)
Pulmonary oedema is a life threatening condition and therefore requires immediate actions to avert further
deterioration or even death. It should therefore be handled with uttermost care. Emergency care precaution
like intubation, supplemental oxygen and resuscitation should be anticipated. Moreover, it requires high
level of expertise and team work in managing the patient. (Chronic kidney disease: practice essentials,
pathophysiology, etiology, 2018)

CARE PLAN TEMPLATE
1. Actual nursing
diagnosis with related to
and evidenced by
statements
Goal of care including SMART
outcome criteria
Priority Nursing actions (4) including specific
detail
Rationales for actions clearly explained with
in text reference
Ineffective gaseous
exchange related to
pulmonary oedema
secondary to heart failure
as evidenced by crackles
in both lungs on
auscultation, elevated
respiratory rate of 28,
decreased oxygen
saturation of 89%,
breathlessness on
mobilisation and feeling
lethargic and tired.
(Carpenito, 2017)
Mr Ron Fraser will demonstrate
improved gaseous exchange
after three hours of nursing care
by having oxygen saturation rate
of 95%, increase in comfort level
and improved breathing during
activity/exercise
 Administer oxygen through non-rebreather
mask at 10-15l/per min.
 Nurse Mr Ron in semi-fowler position and
assess Ron’s pulse oximetry readings,
respiratory rate at every interaction or hourly.
 Administer diuretics like Lasix 60mg BD
according to the doctor’s prescription
 Promote and ensure the patients gets good
bed rest. Talk to the patient about his
condition and assure him of care.
 Supplemental oxygen reduces hypoxia
by availing more oxygen to the lung for
perfusion.(Carpenito, 2017)
 Semi-fowler position improves breathing
by reducing the work of breathing and
enhancing lung expansion. The routine
assessments will help to help to
determine if the interventions are
working or there is need for change.
(Carpenito, 2017)
 Administering diuretics helps to increase
fluid loss through the kidneys thus
reducing the water load in the body.
Lasix (furosemide) is a loop diuretic that
facilitates the loss of water without
reabsorption of salt and is suitable for
management of oedema and fluid
overload in the body.
(Carpenito, 2017)
 Talking builds a therapeutic relationship
and rapport based on empathy. A bed
rest will minimize energy loss by the
body. (Gordon, 2010)

CARE PLAN TEMPLATE
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