Assessment Explanatio Objectives Nursing Rationale Evaluation

n of the intervention
problem
Subjective: Ineffective STO: Dx: Dx: STO:
-“Nahihirapan breathing After 8  Assess breath  To note for After 8
ako huminga. pattern hours sounds, respiratory hours
“ occurs when of nursing respiratory abnormalities of nursing
inspiration intervention rate, depth that may intervention,
Objective: and , and rhythm indicate early the patient
- tachycardic expiration the patient (shortness of respiratory was able to
-shortness of does not will be able breath) compromise demonstrate
breath provide to and hypoxia appropriate
-pale in color adequate demonstrat  Assess for pain  Pain may coping
ventilation. e and discomfort restrict or behaviors
appropriate limit and methods
Nursing coping respiratory to improve
diagnosis: behaviors effort breathing
Ineffective and  Monitor for  Careful pattern and
breathing methods signs and assessment maintain
pattern to improve symptoms of provides for serum
related to breathing respiratory early potassium
increased pattern and distress recognition level within
serum maintain and normal range
potassium serum intervention GOAL MET
level as potassium for problem
evidenced by level within  Monitor serum  To evaluate LTO:
shortness of normal potassium as therapy After 3 days
breath and range indicated needs and of nursing
serum effectiveness intervention,
potassium LTO: Tx: Tx: the patient
level of 6.5 After 3 days  Provide  To promote was able
mEq/l of nursing relaxing adequate rest to apply
intervention environment periods to techniques
, limit fatigue that may
the patient  Assist patient  To provide improve
will be able in the use of relief of breathing
to apply relaxation causative pattern and
techniques technique factors be free from
that may  Elevate the  To minimize signs and
improve head of the the difficulty symptoms of
breathing head of the in breathing respiratory
pattern and bed and and to distress and
be free change promote lung verbalize
from position every expansion causes of
signs and 2 hours hyperkalemia
symptoms  Administer  To treat in related to
of prescribed bacterial renal failure
respiratory antibiotic infection if it GOAL MET
 distress and medications is the
verbalize underlying
causes of cause of the
hyperkalemi patient’s
a in related condition
to renal  Demonstrate  To decrease
failure diaphragmatic air trapping
and pursed-lip and for
breathing efficient
breathing
Edx: Edx:
 Encourage  To prevent
opportunities situations
for rest and that will
limit physical aggravate
activities. the condition
 Encourage  To maximize
deep breathing effort for
and coughing expectoration
exercises.
 Emphasize the  To maximize
importance of respiratory
good posture effort
and effective
use of
accessory
muscles

Time Chart
8:00-4:00 F> Ineffective breathing pattern related to increased serum
pm potassium level as evidenced by shortness of breath and serum
potassium level of 6.5 mEq/l
D> “nahihirapan ako huminga”; received lying on bed; tachycardic
and with shortness of breath; pale in color.
A> Assessed breath sounds, respiratory rate, depth and rhythm
(shortness of breath); assessed for pain and discomfort; monitored
for signs and symptoms of respiratory distress; monitored serum
potassium as indicated; provided relaxing environment; assisted in
the use of relaxation technique; elevated the head of the bed and
change position every 2 hours; administered prescribed medications;
demonstrated diaphragmatic and pursed-lip breathing; encouraged
opportunities for rest and limit physical activities; encouraged deep
breathing and coughing exercises; emphasized the importance of
good posture and effective use of accessory muscles
R> After 8 hours of nursing intervention, the patient was able to
demonstrate appropriate coping behaviors and methods to improve
breathing pattern and maintain serum potassium level within normal
 range

My prioritization from this case is ensuring first her breathing pattern following the
ABC pattern:
1. Ineffective breathing pattern related to increased serum potassium level as
evidenced by shortness of breath and serum potassium level of 6.5 mEq/l
2. Decreased cardiac output related to hyperkalemia as evidence by tachycardia
3. Activity intolerance related to skeletal muscle weakness