ASSESSMENT NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS

Subjective Cues : Impaired gas exchange Increased capillary After 8 hours of nursing Independent: After 8 hours of nursing
“Nakukurian ako pag related to pulmonary interventions, the patient 1. Assess respiratory 1. Rapid and shallow interventions, the patient
hydrostatic pressure,
hinga” as verbalized. congestion as will be able to: rate, depth, and breathing patterns has been able to:
evidenced by exertional promoting movement effort, including and hypoventilation
Objective Cues: dyspnea, crackles and of fluid into the a. Maintain optimal use of accessory affect gas exchange. a. Maintain
cough with frothy pink interstitial space of gas exchange as muscles, nasal Increased respiratory optimal gas
- Use of sputum.. evidenced by flaring, and rate, use of exchange as
the alveolar-capillary
accessory respirations at abnormal accessory muscles, evidenced
muscles membrane. Initially, 12-20 per minute, breathing patterns. nasal flaring, by oxygen
- Exertional increased lymphatic oxygen saturation abdominal saturation
dyspnea flow removes the results within breathing, and a results
- Tachypnea normal range. look of panic in the within
excess fluids, but patient’s eyes may
- Nasal flaring normal
was seen. continued leakage be seen with range.
- Crackles was eventually hypoxia.
heard upon overwhelms this b. Verbalize b. Verbalize
auscultation understanding of 2. Assess the lungs 2. Any irregularity of understandin
mechanism. Gas for areas of breath sounds may
- Cough with oxygen and other g of oxygen
exchange becomes therapeutic decreased disclose the cause of and other
frothy pink
sputum and impaired by the thick interventions. ventilation and impaired gas therapeutic
coffee ground auscultate exchange. Presence interventions
membrane.
sputum (nov presence of of crackles and .
Increasing interstitial c. Participate in adventitious wheezes may alert c. Participate
23) was noted.
fluid pressure procedures to sounds. the nurse to an in
- O2 at 3 L/min
ultimately causes optimize airway obstruction, procedures
oxygenation and which may lead to to optimize
leaks into the alveolar
in management or exacerbate oxygenation
Measurement: sacs, impairing regimen within existing hypoxia. and in
ventilation and gas level of Diminished breath management
T: 36.5°C
exchange. capability. sounds are linked regimen
RR: 24 cpm
with poor within level
PR: 90 bpm
ventilation. of
: Source: capability.
Hawks. J, & Black, J.
(2009. Medical 3. Monitor oxygen 3. Pulse oximetry is a
saturation useful tool to detect
Surgical Nursing (8th
continuously, changes in
ed., p. 1636). using pulse oxygenation. An
oximeter. oxygen saturation of
Saunders, an imprint
<90% (normal: 95%
of Elesvier Inc. to 100%) or a partial
pressure of oxygen
of <80 (normal: 80
to 100) indicates
significant
oxygenation
problems.

4. Position patient 4. Upright position or

with head of bed semi-Fowler’s
elevated, in a position allows
semi-Fowler’s pos increased thoracic
ition (head of bed capacity, full
at 45 degrees descent of
when supine) as diaphragm, and
tolerated. increased lung
expansion
preventing the
abdominal contents
from crowding.
5. Turn the patient
every 2 hours. 5. Turning is important
to prevent
complications of
immobility.
6. Administer O2
regulated at 3 6. For management of
L/min via nasal underlying
cannula as pulmonary condition
ordered. and respiratory
distress

7. Instruct patient to
limit exposure to 7. This is to reduce the
persons with potential spread of
respiratory droplets between
infections. patients.

Collaborative:
8. Administer
prescribed 8. To produce
medications to open therapeutic effects
the airways of the such as:
lungs such as:
 Salmetrol +
Fluticasone  Selectively
25/250 mcg 2 activates beta 2
puffs BID adrenergic
receptors, which
results in
bronchodilation
and blocks the
release of
allergic
mediators from
the mast cells in
the respiratory
 Salbutamol + tract.
Ipratopium 1
neb  After
acetylcholine is
released from
cholinergic
fibers,
ipratropium
prevents it from
attaching to
muscarinic
receptors on
membranes of
smooth muscle
cells.