ASSESSMENT DIAGNOSIS OUTCOME PLANNING INTERVENTION EVALUATION

IDENTIFICATION
Subjective Data: Impaired gas Patient maintains At the end of 8 hours of INDEPENDENT: The goal was met. The
“Nahihirapan po akong exchange related to optimal gas exchange nursing intervention -Position patient with head of bed patient was able to
huminga “ as verbalized by altered oxygen as evidenced by usual the patient will be able elevated, in a semi-Fowler’s position verbalized the
the patient. supply mental status, to verbalizes R: increased lung expansion understanding of the
unlabored understanding of preventing the abdominal therapeutic
respirations at 12-20 oxygen and other contents from crowding. organization and was
Objective Data: per minute range, and therapeutic able to participate in
- Abnormal breathing (rate, baseline HR for interventions and -Maintain an oxygen administration the procedure.
depth, rhythm) patient. participates in device as ordered, attempting to
-Irritability procedures to optimize maintain oxygen saturation at 90%
-Pallor oxygenation and in or greater.
-Restlessness management regimen R: Supplemental oxygen may be
-Tachycardia within level of required to maintain PaO2 at an
Vital Sign: capability/condition. acceptable level.
BP: 130/90mmHg
PR: 110bpm -Encourage slow deep breathing
RR:26cpm using an incentive spirometer as
T:37.3 C indicated.
R: These technique promotes
deep inspiration, which increases
oxygenation and prevents
atelectasis

-Pace activities and schedule rest

periods to prevent fatigue. Assist
with ADLs.
R: Activities will increase oxygen
consumption and should be
planned so the patient does not
become hypoxic.

-Provide reassurance and reduce

anxiety.
R: Anxiety increases dyspnea,
respiratory rate, and work of
breathing.