ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

• “katatapos lang Impaired gas exchange After 3 days of SUPLEMENTAL: The clients condition
ng duty nya na related to altered nursing intervention is improved as
24hours nung delivery of oxygen. the client will be able DEVELOPMENTAL: evidence by:
umuwi sya sa to have a proper gas
bahay tapos exchange by FACILITATIVE: -disappearance of
naglaba sya ng
wheezing and
mga damit hindi
pa sya crackles sounds over
nakakatulog nun his lung fields.
simula nung
duty nya tapos -client’s nailbed color
nung hapon nag retured into its
bike sya. normal color which is
Pagdating nya pinkish.
sa bahay medyo
nahihirapan na
sya huminga
kaya uminom na
sya agad ng
gamot.
Pagkatapos nun
naayos yung
paghinga nya.
Tapos
nagsigarilyo sya
ng 1 stick na
Marlboro. Tapos
nung bandang
10:00 p.m,ayun
sinumpong ulit
sya ng hika nya,
pero mas malala
kesa dun sa una
kasi hinimatay
sya.”
• Mr. XXX was
brought in
Bulacan
 Polymedic
Hospital due to
difficulty of
breathing before
going to bed.
• He was
lethargic and
has cyanosis
over his face.

OBJECTIVE:

• Crackles and
wheezes are
heard over his
lung fields with
a blood pressure
of 200/110
mmHg.
• He has an
oxygen supply
from the oxygen
tank with the
volume of 3-4L
pm NaNC.
• Wheezing
and crackling
sounds
• Decreased
chest expansion.

• The client’s
 nail bed color is
dark pink
SUBJECTIVE: Ineffective breathing After 3 days of SUPLEMENTAL: The clients condition
• During the pattern related to nursing intervention is improved as
insertion of the anxiety. the client will be able DEVELOPMENTAL: evidence by:
catheter Mr. to decrease his -BP=120/80
XXX panicked anxiety FACILITATIVE: -not restless
because he was
by……./effective
afraid that he
feel the pain breathing pattern by
upon the having an adequate
insertion of rest and decreasing
catheter and the pain due to his
caused him to folly catheterization.
trigger his
asthma.
• He verbalized
that “hindi ako
makahinga ng
ayos lalo na pag
sumasakit yung
pakiramdam ko
dahil sa catheter
na nakakabit sa
akin.”
OBJECTIVE:
• Looks tired and
restless
• There are signs
of distress in the
client’s posture
and facial
expression.
• BP=150/100
mmHg
SUBJECTIVE: Activity intolerance SUPLEMENTAL: The clients condition
• He verbalized related to dyspnea. is improved as
 that "hanggang DEVELOPMENTAL: evidence by:
10 minutes lang -disappearance of
ang kaya ko FACILITATIVE: wheezing and
dahil hinihingal crackling sounds.
ako pag matagal
-
akong nagja
jogging."
• He cannot
exercise with his
present
condition
because of his
asthma he
experienced
difficulty of
breathing.
OBJECTIVE:
• Barrel chest
• Wheezing and
crackling sounds
• Resting in bed