ASSESSMENT NURSING BACKGROUND PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS KNOWLEDGE
Subjective: Impaired Gas Short term: Independent: Independent: After 5 hours of
Exchange related nursing
“ Nahihirapan to altered oxygen Afte 5 hours of 1. Assess the 1. Useful in intervention
akong humingi as supply nursing characteristics of evaluating the
verbalized by the obstruction of intervention respirations. degree of  The patient
patient” airways by (Note: Heart rate respiratory demonstrated
secretions  The patient and Use distress or adequate
Objective: (e.g chronic will accessory chronicity of the oxygenation
cough) as demonstrate muscles) disease process. with ABGs
Vital Signs: evidenced by adequate within normal
abnormal ABG oxygenation 2. Assess and 2. Respirations may limits.
BP - 130/80 values and with ABGs monitor be shallow and
RR - 30 dyspnea within respirations and rapid, with  The patient
normal breath sounds, prolonged denied any
ABG result: limits. noting rate and expiration in difficulty of
sounds comparison to breathing.
Ph - 7.24,  The (tachypnea, inspiration
PO2 - 35 mmHg, patient will stridor, crackles,  The patient is
PCO2 - 60mmHg, deny any wheezes). Note free of any
HCO3 – 30 difficulty of inspiratory and signs of
O2 sat - 85%. breathing.  expiratory ratio. respiratory
distress.
Other: 3. Monitor O2 3. Pulse oximetry
 The
 Respiratory saturation and reading of 87% THE GOAL WAS
patient will
distress titrate oxygen to below may MET
be free of any
 Use accessory maintain Sp02 indicate the need
signs of
muscles between 88% to for oxygen
respiratory 92%. administration
 Dyspnea distress. while a pulse
oximetry reading
of 92% or higher
may require
oxygen titration.
4. Assist the patient
in an upright (30 4. A proper body
to 45 degrees) alignment allows
position as their for adequate
 condition allows. lung expansion
and movement
of respiratory
muscles to
support the
lungs.

5. Adjust the 5. Frequent

position adjustment helps
frequently maintain a
correct body
alignment for
easier ventilation
and gas
exchange.

6. .Auscultate 6. Some degree of

breath sounds. bronchospasm is
Note present with
adventitious obstructions in
breath sounds the airway and
(wheezes, may or may not
crackles, be manifested in
rhonchi). adventitious
breath sounds
such as scattered,
moist crackles
(bronchitis);
faint sounds,
with expiratory
wheezes
(emphysema); or
absent breath
sounds (severe
asthma).
 7. Monitor and 7. Establishes a
graph serial baseline for
ABGs, pulse monitoring
oximetry, chest progression or
x-ray. regression of
disease process
complications.

Dependent: Dependent:

1. Administer 1. Supplemental
oxygen as oxygen improves
ordered to gas exchange
maintain oxygen and oxygen
saturation above saturation.
90%.

2. administer 2. the treatment of

medication as acute asthma
doctors ordered produces a small
(salbutamol and improvement in
ipratropium) lung function,
and reduces the
risk of the need
for additional
treatment,
subsequent
asthma
exacerbations,
and
hospitalizations.
NCP – COPD
PATIENT ASSESSMENT
AGE: 56 yrs old