Assessment Nursing Diagnosis Nursing Outcome Intervention Implementation Evaluation

Subjective Cues: Risk for impaired Gas After 8 hours of Independent Independent After 8 hours of Nursing
"nurse, ang higpit exchange related to, Nursing intervention, patient will be
ng pakiramdam ko alveolar-capillary intervention, the  Determine the presence  Determined the able to manifested a
dito sa dibdib ko, membrane patient will be of factor/physical condition as noted respiration had improved
paminsan accumulation of fluids manifesting, an condition as noted in in related to momentary, evidence by:
hinihingal ako in interstitial space of effective gas related to. decreased lung
bigla, kahit alveoli, evidenced by exchange, and -(1+) as mild Edema
expansion
nakaupo lng ako difficulty of breathing improvement of Rationale: It can be multiple
nurse, tapos bigla and presences of perfusion of blood -Respiratory rate of patient
factors, including anemias,  Auscultated and
bigla ako tatayo crackles sound and oxygenation of had decreased with in 32,
allergic reaction, surgical percussed chest
nahihiro ako"as the body, evidence down to 23bmp
procedure, altered level of
verbalized by by: consciousness, and etc.
patient -Reduced edema in  Noted rate depth of -Reduced Difficulty of
extremities respiration breathing
Objective Cues:  Auscultation and
percuss chest.
-Respiratory rate of  Evaluated cough
-As noted in patient had and presences of
auscultation, with decreased with in Rationale: In this nursing
diagnosis, ventilatory effort is secretion (Dry
crackles sound 32, down to 23bmp
insufficient to deliver enough Cough)
-Murmur sound in -Reduced Difficulty oxygen or to get rid of sufficient
auscultation of of breathing amount of carbon dioxide.
heart  Elevate the head of
 Note rate depth of the bed, and/or have
-Respiratory rate: respiration the Patient sitting
35 bpm (semi-fowlers)
Rationale: This provides insight
-O2 sat: 70% at into the work of breathing and  Encouraged a
room air adequacy of alveolar ventilation. position of comfort,
repositioned patient
-Weight: 55 kg frequently if
immobility is factor
-Blood pressure:  Evaluate cough and
140/80 presences of secretion  Provided an
elevation of feet to
-Temperature: 36°C Rationale: this affects the ability reduce the edema in
to clear airways of secretion. extremities.
-Pulse rate: 100
bpm  Elevate the head of the
bed, and/or have the  Provided
Patient sitting (semi- ambulation/exercise,
fowlers) as individually
indicated
Rationale: Elevation or upright
position facilitate respiratory
 Managed adequate
function by gravity.
rest period between
 Encourage a position activities
of comfort, reposition
patient frequently if
 Established the
immobility is factor
recommended
Rationale: This promote optimal energy conservation
chest expansion, mobilization of techniques and
secretion, and oxygen diffusion. pacing activities.

 Promoted surface
 Encourage an elevation cooling by means of
of feet to reduce the undressing
edema in extremities.
 Monitor use of
Rationale: Improvement of the hypothermia
travel of the fluid, in which blankets and wrap
evidence of ineffective perfusion extreme ties with
of fluid. bath towels
(minimize
 Encourage shivering)
ambulation/exercise, as
 individually indicated
 Provided by a high
Rationale: This promote optimal caloric diet in
chest expansion, mobilization of Parenteral or enteral
secretion, and oxygen diffusion. nutrients to (soft
diet)
 Encourage adequate
rest period between  Provided a proper
activities adequate fluid
Rationale: this help limit oxygen intake (to prevent
needs and consumption) any dehydration)

Dependent
 Recommend energy  Given by the
conservation Medication with, as
techniques and pacing prescribed by
activities. physician
Rationale: this manifest Collaboration
improved energy reservation, that
initiate proper recovery.
 Administered
oxygen at the low
 Promote surface concentration
indicated and
cooling by means of
prescribed
undressing.
respiratory
Rationale: To reduces, metabolic medication.
mechanism)
 Assisted the patient
in the use of
 Monitor use of relaxation
hypothermia blankets techniques (pursed-
and wrap extreme ties lip breathing.)
 with bath towels  Demonstrated Splint
the rib cage during
Rationale: To minimize shivering deep-breathing
exercise/cough if
indicated
 Provide high caloric
diet in Parenteral or
enteral nutrients to
(soft diet)

Rationale: To increased
metabolic requirement during
recovery.

 Give proper adequate

fluid intake

Rationale: to prevent any

dehydration.

Dependent

 Administer medication,
as indicated

Rationale: Pharmacological
agents are varied, specific to the
client, but general used to prevent
and control symptoms, reduced
frequency and severity of
exacerbation.

Collaboration
 Administer oxygen at
 the low concentration
indicated and
prescribed respiratory
medication

Rationale: to improved
respiration function/oxygen
carrying capacity.

 Assist the Patient in the

use of relaxation
techniques

Rationale: To reduced anxiety

and stress

 Demonstrate Splint the

rib cage during deep-
breathing
exercise/cough if
indicated

Rationale: The mode of

ventilation, will be mobilized of
proper mechanisms of muscle
movement.

Source: Impaired gas exchange, p 374 – 379. NANDA 15th edition.