D.
Nursing Care Plan
ASSESSMENT
SUBJECTIVE DATA
“Nahihirapan talaga siya
huminga” as verbalized by
patient’s daughter
OBJECTIVE DATA
 Difficulty of breathing
 Restlessness
 Hypoxemia
 Dependence on O2
supplementation of 3
lpm
DIAGNOSIS PLANNING
Impaired gas exchange After 8 hours of nursing
related to altered oxygen interventions, the client
supply as evidenced by will:
difficulty in breathing
 Demonstrate improved
ventilation and
adequate oxygenation
of tissues by increased
O2 saturation
 Patient indicates,
either verbally or
through behavior,
feeling of less
respiratory distress
INTERVENTIONS RATIONALE EVALUATION
 Place patient with  A sitting position After 8 hours of nursing
proper body alignment permits interventions, the client
for maximum breathing maximum lung was able to:
pattern. excursion and
chest expansion.  Demonstrate
improved
 Note respiratory rate,  Respirations may ventilation and
depth and ease. observe be increased as a adequate
for use of accessory result of pain oxygenation of
muscles, pursed- lip tissues by increased
breathing, changes in O2 saturation
skin or mucous
membrane, pallor,  Patient indicates,
cyanosis either verbally or
through behavior,
Encourage sustained deep  These feeling of less
breaths by: techniques respiratory distress
 Using demonstration: promotes deep
highlighting slow inspiration,
inhalation, holding end which increases
inspiration for a few oxygenation and
seconds, and passive prevents
exhalation atelectasis.
 Utilizing incentive Controlled
spirometer breathing
 Requiring the patient to methods may
yawn also aid slow
respirations in
patients who are
tachypneic.
Prolonged
expiration
prevents air
D. Nursing Care Plan

trapping.

 This prevents
 Encourage small crowding of the
frequent meals. diaphragm

 These measures
Teach patient about: allow patient to
 pursed-lip breathing participate in
 abdominal breathing maintaining
 performing relaxation te health status and
chniques improve
 performing relaxation ventilation.
techniques
 taking prescribed
medications (ensuring
accuracy of dose and
frequency and
monitoring adverse
effects)
 scheduling activities to
avoid fatigue and
provide for rest periods