ASSESSMENT Subjective: "nahihirapan ako huminga as verbalized by the patient.

Objective: BP 100/60 mmHg , CR- 83/min RR18 (- ) Easy fatigability , (-)Orthopnea, (+) exertional dyspnea (+) SOB Ambulatory

DIAGNOSIS
Ineffective breathing pattern related to altered

heart rate, rhythm, as

manifested by shortness of breath and faint systolic

PATHOPHYSIOLOGY PLANNING After 30 minutes Backward heart of nursing failure intervention the client will have a Aortic stenosis limits feeling of relief forward flow of blood from shortness of from LV Aortic breath
regurgitation permits blood flow back in the LV from the aorta

INTERVENION -Monitor vital signs -Elevated head of the bed for about 30 degrees and ask the client to assume dorsal recumbent position -Encouraged deep breath exercises

murmur over the apex

Left ventricular hypertrophy and dilatation Increased blood volume and pressure in LV

RATIONALE -for initial data base reference -elevation of the bed facilitates respiratory function by use of gravity. It also decreases pressure on the abdomen when assuming the position -promote chest expansion

EVALUATION After 30 minutes of nursing intervention the client had a feeling of relief from shortness of breath

Increased blood volume and pressure in left Atrium

-Monitored respiratory patterns including rate, depth and effort

-assess the condition of the client

Left atrium hypertrophy and dilatation Increased blood volume and pressure in pulmonary veins

-helps in giving -Give adequate oxygen supplemental to the client oxygen as ordered (2LPM via nasal cannula)as ordered by th physician

Pulmonary

congestion(shortness of breath and pulmonary edema)