Zuellen Mae G.

Bedaño BSN
Cues Nursing Outcome Interventio Rationale Evaluation Discharge
Diagnosis Criteria n Planning

Subjective: Ineffective Short-Term: Independen Independ Short term: M​edication

Breathing After 15-30 t: ent : : • Advise
Pattern r/t •Monitor VS •Provide After patient the
-Complained mns. of
Multiple as importanc
15-30mns.
Difficulty of Bruises nursing baseline e of
breathing data of nursing following
intervention,
•​Encourage •​To assist correctly
intervention,
Objective : the patient deep in muscle regarding
breathing and the patient : her home
will be able
- Systolic BP=80 exercises. generalize medication
to: d s:
-Maintain
-PR=120bpm relaxation.
-Maintain
(Sinus •Assist the adequate E​nvironme
adequate patient with •Aid pain nt:•
tachycardia) oxygenation
positioning reduction Encourage
oxygenation
(Semi-Fowle and for -Maintain client and
-RR=36bpm
-Maintain r) effective family to
adequate
-Multiple bruising breathing provide a
adequate
pattern circulating clean,
and abrasions on peaceful,
circulating
the R side of blood
•Provide •​Promotes stress-free
chest blood volume
relaxation volume and well
nonpharmac
-demonstrate and helps ventilated
-Pale, Cool to -demonstrat
ological refocus environme
touch, d the use of
attention. ed the use nt
comfort
Diaphoretic appropriate conducive
of
measures for
diversional
-Open Fracture appropriate recovery
(massage,
of L ankle activities and and
diversional
repositionin healthy
relaxation
activities living.
g, backrub)
skills.
and
and T​reatment:
relaxation Strictly
diversional
adhere to
skills.
activities the
prescribed
(music,
regimen
television) by the
physician.
•Note for
•Restlessn
changes in ess, H​eath-Tea
confusion, ching:
level of
and/or -Encourag
consciousne irritability e frequent
can be rest
ss.
early periods
indicators and teach
of patient to
insufficient pace
 oxygen to activity.
the brain. -Educate
patient or
Dependent: Dependen significant
t: other
•Provide
•Beta-adre proper
respiratory
nergic breathing,
medications
agonist coughing,
and oxygen,
medication and
per doctor’s
s relax splinting
orders.
airway methods.
smooth O​ut-patien
muscles t:Seek
and cause consultatio
bronchodil
n follow-up
ation to
open air check-up
passages. as advised
to monitor
•Administer
•For the
and Monitor
hydration patient's
IV fluids as
prescribed condition
and for
Collabora detection
Collaborati of
tive :
ve:
•For recurrence
•Provide
nutritional s and
and
needs other
implement
prescribed complicati
dietary on that
modification may arise
•Helps to
s on it.
monitor
•Monitor lab
the
studies
patient's D​iet:
condition • Strictly
and the
follow the
effectivene
ss of prescribed
nursing diet.
care.
S​upport/S
•Refer
•Exercise piritual:En
patient for
promotes courage
evaluation
conditionin
of exercise the family
g of
potential to seek
respiratory
and spiritual
muscles
developmen
and support
t of
patient’s groups or
individualize
sense community
d exercise
of resources
program.
well-being.
•
for the
patient.