DATE & TIME

JULY 29, 2016

8:00 PM

CUES

NEEDS

NURSING
DIAGNOSIS

Subjective:
Nalisdan jus log
hinge. as verbalized
by the patient.

A
C
T
I
V
I
T
Y

Impaired gas
exchange related to
impaired diffusion of
Gases Associated
with Accumulation of
Fluid in the
Pulmonary Interstitial
and Alveoli

Objective:
1.
2.
3.
4.
5.

Dyspnea
Slow respiration
Restlessness
Cough
Adventitious
breath sounds
(wheezing)

Vital Signs:
BP - 110/70
T - 37.PR - 85
RR - 12

E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

GOAL OF CARE

NURSING
INTERVENTIONS

After 6-8 hours of

1. Note presence of
nursing interventions,
related factors.
the patient will be
R: Gas exchange
able to:
problems can be
related to multiple
1. Demonstrate
factors.
improved
ventilation and
2. Note respiratory
adequate
rate, depth, use of
oxygenation of
accessory muscles,
tissues by ABGs pursed-lip breathing;
within clients
areas of pallor or
usual parameters cyanosis.
and absence of
R: Provides insight
symptoms of
into the work of
respiratory
breathing and
distress.
adequacy of alveolar
ventilation.
2. Verbalize
understanding of
3. Auscultate breath
causative factors and sounds, note areas of
appropriate
decreased
interventions.
adventitious breath
sounds as well as
3. Participate in
fremitus.
treatment regimen
R: Ventilatory effort is
within level of ability
insufficient to deliver
or situation.
enough oxygen or to
get rid of sufficient
amounts o carbon

EVALUATION
overall : GOAL
PARTIALLY MET
(GOAL NOT MET)
Patient was not able
to:
1. Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients
usual parameters
and absence of
symptoms of
respiratory
distress
Positive signs of:
Dyspnea
2. Slow respiration
3. Restlessness
4. Cough
5. Adventitious
breath sounds
(wheezing)
RR - 12

DATE & TIME

JULY 29, 2016
8:00 PM

CUES

NEEDS

NURSING
DIAGNOSIS

Subjective:
Nalisdan jus log
hinge. as verbalized
by the patient.

A
C
T
I
V
I
T
Y

Impaired gas
exchange related to
impaired diffusion of
Gases Associated
with Accumulation of
Fluid in the
Pulmonary Interstitial
and Alveoli

Objective:
1.
2.
3.
4.
5.

Dyspnea
Slow respiration
Restlessness
Cough
Adventitious
breath sounds
(wheezing)

Vital Signs:
BP - 110/70
T - 37.PR - 85
RR - 12

E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

GOAL OF CARE

NURSING
INTERVENTIONS

After 6-8 hours of

1. Note presence of
nursing interventions,
related factors.
the patient will be
R: Gas exchange
able to:
problems can be
related to multiple
1. Demonstrate
factors.
improved
ventilation and
2. Note respiratory
adequate
rate, depth, use of
oxygenation of
accessory muscles,
tissues by ABGs pursed-lip breathing;
within clients
areas of pallor or
usual parameters cyanosis.
and absence of
R: Provides insight
symptoms of
into the work of
respiratory
breathing and
distress.
adequacy of alveolar
ventilation.
2. Verbalize
understanding of
3. Auscultate breath
causative factors and sounds, note areas of
appropriate
decreased
interventions.
adventitious breath
sounds as well as
3. Participate in
fremitus.
treatment regimen
R: Ventilatory effort is
within level of ability
insufficient to deliver
or situation.
enough oxygen or to
get rid of sufficient
amounts o carbon

EVALUATION
overall : GOAL
PARTIALLY MET
(GOAL NOT MET)
Patient was not able
to:
1. Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients
usual parameters
and absence of
symptoms of
respiratory
distress
Positive signs of:
Dyspnea
2. Slow respiration
3. Restlessness
4. Cough
5. Adventitious
breath sounds
(wheezing)
RR - 12

DATE & TIME

JULY 29, 2016
8:00 PM

CUES

NEEDS

NURSING
DIAGNOSIS

Subjective:
Nalisdan jus log
hinge. as verbalized
by the patient.

A
C
T
I
V
I
T
Y

Impaired gas
exchange related to
impaired diffusion of
Gases Associated
with Accumulation of
Fluid in the
Pulmonary Interstitial
and Alveoli

Objective:
1.
2.
3.
4.
5.

Dyspnea
Slow respiration
Restlessness
Cough
Adventitious
breath sounds
(wheezing)

Vital Signs:
BP - 110/70
T - 37.PR - 85
RR - 12

E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

GOAL OF CARE

NURSING
INTERVENTIONS

After 6-8 hours of

1. Note presence of
nursing interventions,
related factors.
the patient will be
R: Gas exchange
able to:
problems can be
related to multiple
1. Demonstrate
factors.
improved
ventilation and
2. Note respiratory
adequate
rate, depth, use of
oxygenation of
accessory muscles,
tissues by ABGs pursed-lip breathing;
within clients
areas of pallor or
usual parameters cyanosis.
and absence of
R: Provides insight
symptoms of
into the work of
respiratory
breathing and
distress.
adequacy of alveolar
ventilation.
2. Verbalize
understanding of
3. Auscultate breath
causative factors and sounds, note areas of
appropriate
decreased
interventions.
adventitious breath
sounds as well as
3. Participate in
fremitus.
treatment regimen
R: Ventilatory effort is
within level of ability
insufficient to deliver
or situation.
enough oxygen or to
get rid of sufficient
amounts o carbon

EVALUATION
overall : GOAL
PARTIALLY MET
(GOAL NOT MET)
Patient was not able
to:
1. Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients
usual parameters
and absence of
symptoms of
respiratory
distress
Positive signs of:
Dyspnea
2. Slow respiration
3. Restlessness
4. Cough
5. Adventitious
breath sounds
(wheezing)
RR - 12