Nursing Care Plan For Respiratory Tract Problems

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ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION

DIAGNOSIS

Date: December  Impaired gas  After 1 hr  Administer O2  After 1 hr of


21, 2008 exchange patient's tank. giving
related to breathing intervention
Patient: 25 y/o
difficulty of pattern should patient's
 Position client
breathing. normalize. breathing
into semi-
pattern is
fowlers
S/O normal.
 After 1 hr position.
patient's BP
"Nahihirapan akong should be  After 1 hr of
 Give
huminga." As decreased. giving
antihypertensi
verbalized by the intervention
ve drugs as
patient. patient's BP is
prescribe by
decrease.
the physician.
[x] pale in color
*Goal partially met.
Vital Signs:

RR: 27cpm
PR: 86bpm
Temp: 36.5
BP: 160/80
ASSESSMENT NURSING PLANNING INTERVENTION EVALUATION
DIAGNOSIS

Date: December  Risk for  After the shift  Auscultate  Patient


20, 2008 aspiration patient will be lung sounds experience no
related to free from frequently. aspiration as
Patient: 6mos
presence of aspiration. evidenced by
OGT. noiseless
 Ascertain that
respirations,
feeding tube is
S/O clear breath
in correct
sounds.
position.

"Medyo ok naman *Goal met.


siya. Pagpinapakain  Determine
kumakain naman." As best position.
verbalized by the
mother.

[x] Oral Gastric Tube

Vital Signs:
RR: 50cpm
Temp: 36.7
CR: 130bpm

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