Patient Initial: GT Student Name: Venus Bonglay

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUATION

ACTION RATIONALE
Nursing Assessment: 1.Ineffective 1.After 24 hours 1.Assess resident vital signs -To assist in creating an Goal Meet:
Ms. GT is a 77-year-old retired Breathing of nursing and characteristic of accurate diagnosis and After 24 hours of
elementary teacher. She was Patterns related intervention. The respiration at least every 4 monitor effectiveness of evaluation the
admitted voluntarily on March to impaired patient will hours medical treatment. resident respiratory
12, 2021, at Kiwanis Home regulation achieve effective rate is 18bpm, it is
care facility due to unable to secondary to breathing 2.Encourage the resident -Sleeping on one’s back within the normal
care herself. Ms. GT has a sleep apnea as patterns as to sleep in side-lying increase the chance of range, O2 Sat 96% on
short-term memory problem evidence by evidence by position and avoid supine throat muscle to relax room air and
but had the ability to break in respiratory rates position as possible. and the airway. absence of cyanosis.
understand others and making breathing between 12 to 20
self-understand, with the during sleep, breath per 3.Hook the resident -To maintain airflow Goal partially meets:
history of obstructive sleep pallor, shallow minutes, oxygen continuous positive airway during sleep.
apnea and using CPAP. She is breathing and saturation within pressure (CPAP) machines After 24 hours of
on full code and the degree of changes the target range, or other devices as evaluation, skin
intervention is C2. respiratory and absence of prescribed by the doctor. pallor still visible to
depth. pallor and Resident.
History of Surgery: cyanosis. 4.Elivate the bed slightly
prior to sleep. -Head elevation can
prevent airway
Current Medical History: obstruction and improve
the expansion of the
HTN, Arthritis, Renal failure, lungs, enabling the
kidney stones, L leg DVT, L4-L5 patient to breathe more
spinal stenosis, obstructive effectively even when
sleep apnea, morbid obesity, sleep.
multiple large abdominal
hernia, GERD, Peripheral
neuropathy, Diverticulosis,
Hyperlipidemia, gouty, Hx of
UTI. 2.After 1 week of
 intervention the 1.Assess respiratory muscle -Expiratory muscle work Goal meet:
Subjective: resident will system in older adult with harder with the use of
verbalize the the understanding that accessory muscle. After one week of
Patient stated, “I stop ability to breath inspiratory muscle nursing intervention
breathing 25 times during the comfortably. weakens, resulting in a the resident stated:
night.” slight barrel chest. Monitor “my breathing is
respiratory rate, depth, and doing okay, I can
Objective: ease of respiration. breathe
comfortably”.
-
Left leg deep thrombosis 2.Encourage resident to sit -To promote breathing Goal partially meets:
-Protruding left abdomen up upright or stand as and expansion of the
-Swollen leg both tolerated and avoid lying lungs. Resident verbalized:
-Yawning down for prolonged period - “I understand the
-Weakness during the day during the day. importance of
-Pallor exercise, but I cannot
-Wearing of glass to see in 3.Inspiratory muscle stand up so long my
adequate light. training likely improves legs hurt me.”
breathlessness during
Physical Examination: exercise and/or with
BP- 119/90 activities of daily living in
PR-94bpm the client with morbid
RR-18bpm obesity and history of sleep
02 sat: 96% room air. apnea.
Temp: 36.5-degree Celsius
Height: 151 cm 4.Increased client activity -Walking at least 10-20
Weight: 107kg to walking at least two minutes a day is
BMI: 33 severe overweight. time a day as tolerated recommended for those
unable to be in a
structured program
(GOLD, 2017)

After 8 hrs of Goal meet:

Mobility: Impaired gas nursing care the 1.Assess the patient vital -To create a baseline set
Limited mobility due to exchange resident will signs, especially the of observation for the After 8 hours of
morbid obesity and multiple related to demonstrate respiratory rate and depth patient, and to monitor nursing intervention
abdominal hernia. She is using altered oxygen adequate during sleep. any changes in the vital the resident oxygen
4ww. supply oxygenation as signs as the patient saturation is 96%
-unsteady gait secondary to evidence by an receives medical and HR is 94bpm.
sleep apnea as oxygenation treatment
Transfer: evidence by saturation and
Two-person assist using apnea, morbid heart rate within 2.Monitor the color of skin -Peripheral cyanosis
ceiling lift, she able to hold obesity and normal level. and mucous membrane. (bluish discoloration of
properly and has a good grip. heart rate Check for any changes in the skin, earlobes, or nail
below normal consciousness or presence beds) maybe evident with
Nutritional Status: Moderate during sleep. of irritability and hypoxia. Central cyanosis
in diabetic diet, regular restlessness. involving the mucosa may
texture. indicate further reduction
of oxygen levels. Changes
Bed Mobility: Independent, in the level of
she can turn position by consciousness may
herself. indicate the state of
hypoxia or impaired
Dressing: Total Dependence oxygenation of the brain.

Bathing: Total dependence,

schedule of shower every 3.Monitor ABG levels. -To consistently check for
Monday morning. respiratory function by
monitoring the changes
Bladder control: continent in pO2 and pCO2.

Allergies: Ramipril with cough,

Aspirin cause gastrointestinal
upset.
4. Reposition the patient by
 elevating the head of the -To improve the delivery
bed and encouraging her to of oxygen in the airways
sleep in a side-lying and to reduce shortness
position. Encourage pursed of breath and risk for
lip breathing exercise airway collapse.
Lab result: during waking hours.

Short term goal

2.After 8hrs of 1.If patient is obese Goal meet:

nursing consider positioning in -Trendelenburg position
intervention the Trendelenburg position 45 at 45 degrees result in After 8 hours
resident will degree for period as increase tidal volumes rendering nursing
verbalize tolerated. and decreased care the goal was
understanding of respiratory rates. meet as evidence by:
using (CPAP) and 2.Regularly check the
other therapeutic position of the resident so -Slumped positioning Resident
intervention that or she does not slump causes the abdomen to demonstrated how
down in bed. compress the diaphragm to use the CPAP
and limits full lung machine.
expansion.

3 Hook the resident

continuous positive airway -To maintain airflow
pressure (CPAP) machines during sleep.
or other devices as
prescribed by the doctor.

4. Consider the patients

nutritional status -Certain condition affect
lung expansion. Obesity
may restrict downward
movement of the
diaphragm, increasing the
risk for atelectasis,
hypoventilation, and
respiratory infection.
Labored breathing is
present in severe obesity
as a result of excessive
weight of the chest wall.