NURSING EXPECTED

ASSESSMENT PLAN OF CARE EVALUATION

DIAGNOSIS OUTCOME

Subjective: Risk for impaired Independent: Short Term Goal: Goals met
Gas exchange
 patient verbalized related to high  Observe respiratory rate/depth. After 30 minutes of After 30 minutes of
“sumasakit ang abdominal surgical nursing intervention, the nursing intervention the
sugat ko kapag incision  Auscultate breath sounds. client will be able to client demonstrated:
humihinga ako ng demonstrate :
malalim”  Assist patient to turn, cough, and
 “sumasakit din deep breathe periodically.  Effective breathing  Effective breathing
ang sugat ko
kapag bigla  Show patient how to splint  Proper splinting  Proper splinting
akong umuubo” incision when coughing. when coughing when coughing

Objective:  Instruct effective breathing

techniques.
 Patient has Rapid Long Term Goal:
and shallow  Elevate head of bed, maintain
respirations After 8 hours of nursing After 8 hours of
low-Fowler’s position. nursing intervention the
 RR- 25 bpm intervention the client
client established an
 Oxygen  Support abdomen when coughing, will have an improved improved breathing
Saturation: 99% ambulating. breathing pattern as
evidenced by a normal pattern.

Collaborative: respiratory rate (12-

20bpm). RR- 20bpm

 Assist with respiratory treatments,

e.g., incentive spirometer, oxygen
inhalation.

 Administer analgesics before

breathing treatments/ therapeutic
activities.

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