MR GUIAN CARLO P AGATEP, RN

STUDENT NR. 06220004

UST LEGAZPI MAN
N222A & B ADVANCE MEDICAL SURGICAL NURSING 1 & 2
28 SEPTEMBER 2022

ASSESSMENT ANALYSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTIONS

SUPPORTIVE DATA Ineffective Breathing Goal/desired INDEPENDENT: Short Term:

Pattern outcome
Subjective Data: Assess and monitor Changes (such as After 30mins to 1
The patient reports Risk factors may Maintain a respiratory rate, tachypnea, dyspnea, hour of nursing
with easy fatigability include: normal/effective depth, rhythm. Note use of accessory interventions the
Tracheobronchial respiratory pattern, reports of dyspnea muscles) maypatient’s respiratory
obstruction: enlarged free of dyspnea, and use of accessory indicate progression pattern will be
Objective Data: mediastinal nodes cyanosis, or other muscles, nasal of respiratory
normalized as
DIFFICULTY OF and/or airway edema signs of respiratory flaring, altered chest involvement andevidenced by free of
BREATHING (Hodgkin’s and non- distress. excursion. compromise dyspnea, cyanosis
Hodgkin’s); superior requiring prompt and other signs of
With RR of 28 and O2 vena cava syndrome intervention. respiratory distress
Sat level of 93% as (non-Hodgkin’s) with normal vital
initial VS taken prior signs of RR- 15-20,
to consultation Place patient in Maximizes lung O2 Sat of 95%-100%.
position of comfort, expansion, decreases
Presented Elevated usually with head of work of breathing,
Hb and RBC count bed elevated or and reduces risk of
with microcytosis . sitting upright aspiration.
leaning forward
Low to normal EPO (weight supported
level (secondary on arms), feet
polycythemia will dangling.
have a high level)
Elevated WBC count Reposition and assist Promotes aeration of
with basophila with turning all lung segments and
MR GUIAN CARLO P AGATEP, RN
STUDENT NR. 06220004
UST LEGAZPI MAN
N222A & B ADVANCE MEDICAL SURGICAL NURSING 1 & 2
28 SEPTEMBER 2022

Elevated platelets periodically. mobilizes secretions.

(thrombocytosis) and
platelet dysfunction Instruct and assist Helps promote gas
with deep-breathing diffusion and
techniques, pursed- expansion of small
lip or abdominal airways. Provides
diaphragmatic patient with some
breathing if control over
indicated. respiration, helping
to reduce anxiety.

Monitor and Proliferation of WBCs

evaluate skin color, can reduce oxygen-
noting pallor, carrying capacity of
development of the blood, leading to
cyanosis (particularly hypoxemia.
in nailbeds, ear
lobes, and lips).

Assess respiratory Decreased cellular

response to activity. oxygenation reduces
Note reports of activity tolerance.
dyspnea or” air Rest reduces oxygen
hunger,” increased demands and
fatigue. Schedule minimizes fatigue
rest periods and dyspnea.
between activities.

Identify and Aids in reducing

MR GUIAN CARLO P AGATEP, RN
STUDENT NR. 06220004
UST LEGAZPI MAN
N222A & B ADVANCE MEDICAL SURGICAL NURSING 1 & 2
28 SEPTEMBER 2022

encourage energy- fatigue and dyspnea,

saving techniques and conserves energy
(rest periods before for cellular
and after meals, use regeneration and
of shower chair, respiratory function.
sitting for care).

Promote bedrest Worsening

and provide care as respiratory
indicated during involvement and
acute and prolonged hypoxia may
exacerbation. necessitate cessation
of activity to prevent
more serious
respiratory
compromise.

Encourage Anxiety increases

expression of oxygen demand, and
feelings. hypoxemia
Acknowledge reality potentiates
of situation and respiratory distress
normality of and cardiac
feelings. symptoms, which in
turn escalates
anxiety.

Promotes relaxation,
Provide calm, quiet conserving energy
MR GUIAN CARLO P AGATEP, RN
STUDENT NR. 06220004
UST LEGAZPI MAN
N222A & B ADVANCE MEDICAL SURGICAL NURSING 1 & 2
28 SEPTEMBER 2022

environment. and reducing oxygen

demand.

Non-Hodgkin’s
Observe for neck patients are at risk
vein distension, for superior vena
headache, dizziness, cava syndrome,
periorbital and facial which may result in
edema, dyspnea, tracheal deviation
and stridor. and airway
obstruction,
representing an
oncologic
emergency.
Provide support to
family and Development of this
caregivers. complication is very
Encourage open frightening for
expression of patient and family
feelings. because it may
indicate end-stage of
disease process and
approaching death,
especially in the
hospice setting.
Keeping family
informed may
diminish their anxiety
and minimize
transmission to
MR GUIAN CARLO P AGATEP, RN
STUDENT NR. 06220004
UST LEGAZPI MAN
N222A & B ADVANCE MEDICAL SURGICAL NURSING 1 & 2
28 SEPTEMBER 2022

patient.
Provide
supplemental Maximizes oxygen
oxygen. available for
circulatory uptake;
aids in reducing
hypoxemia.
COLLABORATIVE:

Monitor laboratory
studies (ABGs, Measures adequacy
oximetry). of respiratory
function and
effectiveness of
therapy.
Administer
analgesics and Reducing
tranquilizers as physiological
indicated. responses to pain
and anxiety
decreases oxygen
demands and may
Assist with limit respiratory
respiratory compromise.
treatments or
adjuncts, (IPPB, Promotes maximal
incentive aeration of all lung
spirometer) if segments, preventing
appropriate. atelectasis.
MR GUIAN CARLO P AGATEP, RN
STUDENT NR. 06220004
UST LEGAZPI MAN
N222A & B ADVANCE MEDICAL SURGICAL NURSING 1 & 2
28 SEPTEMBER 2022

Assist with
intubation and
mechanical
ventilation. May be necessary to
support respiratory
function until airway
edema is resolved in
Prepare for acutely ill
emergency radiation hospitalized patient.
therapy when
indicated. Treatment of choice
for superior vena
cava syndrome.