Assessment Nursing Diagnosis Scientific Planning Intervention Rationale Evaluation

Explanation
Subjective: Impaired Gas Entry of noxious Discharge Independent: Discharge
“Mabilis ang Exchange related particles or gases Outcome: Outcome
kanyang to altered oxygen to the lungs After 3 days of -Monitor skin and -Duskiness and ACHIEVED:
paghinga” as supply ↓ nursing mucous membrane central cyanosis After 3 days of
stated. (obstruction of Release of intervention the color indicate advanced nursing
airways by mediators client: hypoxemia intervention the
Objective: secretion) as ↓ -Manifest absence client:
-RR: 28 cpm evidenced by Abnormal of wheezes upon -Elevate head of the -Oxygen delivery -Manifested
-PR: 102 bpm wheezes upon inflammation of the auscultation bed, assist patient to may be improved absence of
-wheezes upon auscultation lungs -Attain normal assume position to by upright wheezes upon
auscultation ↓ breathing pattern ease work of suctioning auscultation
-with pulse Chronic of 20 cpm breathing - Attained normal
oxymeter inflammation breathing pattern
-with mechanical -Suction when -Suctioning is of 20 cpm
↓
ventilator needed required when
Scar tissue
cough is ineffective
formation
Short-term for expectoration
↓ outcome: of secretions Short-term
Narrowing of After 2 hours outcome
airway lumen of nursing -Presence of ACHIEVED:
↓ intervention the -Auscultate breath wheezes may After 2 hours
Airflow limitations client: sounds, noting areas indicate of nursing
↓ -Demonstrate of decreased air-flow bronchospasm/ intervention the
Impaired gas improved or presence of retained secretions client:
exchange ventilation and adventitious sound -Demonstrated
↓ adequate improved
wheezes oxygenation of -Decrease of ventilation and
tissues by ABG of: -Palpate for fremitus vibratory tremors adequate
pH:7.35-7.45 suggest fluid oxygenation of
Reference: paCO2: 35- collection or air tissues by ABG of:
Pathophysiology 45mmHg tapping pH:7.35-7.45
by Gold, 4th edition paO2: 80- paCO2: 35-
p.345 95mmHg -External stimuli 45mmHg
-Decrease -Provide quiet may prevent paO2: 80-
respiratory rate environment to allow relaxation or inhibit 95mmHg
from 28cpm to 13 the patient to relax sleep -decreased
cpm respiratory rate
from 28cpm to 13
Collaborative: cpm
-to identify if
-Monitor pulse hypoxia is present
oximetry and ABGs
-to reduce
-Administer dyspnea by
antianxiety, sedative, controlling the
or narcotic agents as anxiety and
indicated(e.g.morhine restlessness
)
-use as aid in
treatment
-Hooked to
mechanical ventilator

Reference:
Nursing care Plan
by Marilyn
Doenges, 7th
edition p.124-125