ASSESSMENT

NSG. DIAGNOSI S

NSG. BACKGROUN D

PLANNING

INTERVENTIONS

RATIONALE

EVALUATION

Outcome Achieved. Impaired gas exchange Nahihirapan po related to akong huminga..at alveolarsumasakit ang ulo capillary ko pag tumatayo membrane as verbalized by the changes patient. (acute respiratory distress syndrome) as Objective: evidenced by  V/S taken as nasal flaring, follows: (+) wheezes and cyanosis. y T- 37.7C y P- 85bpm y R-28cpm y B.P.110/80mmH g Subjective:  (+) Wheezes  Nasal flaring  Restlessness Independent: Entry of noxious Long Term particles or gases Outcome:  Establish to the lungs After 3 days of rapport to the nursing interventions client. Release of the client will be able to: mediators Abnormal inflammation of the lungs Chronic inflammation Scar tissue formation Narrowing of airway lumen Airflow limitations a. Manifest absence of wheezes upon auscultation. b. Attain normal breathing pattern of 20cpm. Short Term Outcome: After 8 hours of nursing of interventions the patient will be able to: a. Demonstrate  Provide  Monitor respiratory patterns, including rate, depth, and effort.  To enhance maximal cooperatio n.  With secretions in the airway, the respiratory rate will increase Long Term Outcome: After 3 days of nursing interventions the client was able to: a. Manifest absence of wheezes upon auscultation. b. Attain normal breathing pattern of 20cpm. Short Term Outcome: After 8 hours of nursing of interventions the patient was able to: a. Demonstrate improved ventilation and adequate

 Monitor skin and mucous membrane color.

 Duskiness and central cyanosis indicate advanced hypoxemi a.

 Chest

 Irritability  Rapid, shallow breathing  Cyanosis  Difficulty of breathing

Impaired gas exchange wheezes

improved ventilation and adequate oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress.

postural drainage, percussion, and vibration as ordered.

physical therapy helps mobilize bronchial secretions.

oxygenation of tissues by ABGs within clients normal limits and absence of symptoms of respiratory distress.

 Position head midline with flexion appropriate for age/condition to open or maintain open airway in at-rest or compromised individual.  Keep quiet environment to allow patient to relax.

 To maintain adequate, patent airway.

 External stimuli will prevent relaxation or inhibit sleep.

Dependent:  Administer medications such as bronchodilat ors or inhaled steroids as ordered.

 Bronchodi lators decrease airway resistance secondary to bronchoco nstriction

Collaborative:  Refer to other health care team members.  For proper interventio ns to be done.