Assessment Diagnosis Planning Intervention Evaluation

Subjective Data: Ineffective After 30 minutes Independent: After doing the

the patient Breathing of nursing nursing
verbalize Pattern intervention the Position the intervention the
“nahihirapan Related to patient will Patient in patients shows
akong huminga” hypoxia as relieve shortness Orthopneic or relief as evidence
evidence by of breath by High Folwer’s of
Objective Data: shortness of evidence of position to (-) restlessness
Restless breath. relaxed breathing promote and able to sleep
RR- 35bpm at a normal rate respiration RR- 23
BP- 70/40mmhg and depth with 02 Sat- 98%
Tachycardia the absence of Encourage the (-) Tachypnea
Using of dyspnea. Patient for deep And goal was
accessory muscle breathing met.
to breathe exercise
O2 Sat- 90%
Pale appearance Provide Chest
Physical Therapy
by back tapping.

Dependent:

Oxygen support
to 6 liter per
minute via Face
Mask as ordered.

Nebulized the
patient with
vasodilator as
ordered
Nursing Notes

1. We take the vital signs of our patient every 4 hours to monitor their status and know if their
any immediate intervention
2. We did wound dressing to the patient, to prevent infection and promote healing
3. changing of bed linen to a patient who is bed ridden
4. fixing an IV with backflow
5. Encourage the patient to move to prevent formation bed sores

Reflection:

As I reflect on my journey as a student nurse, one stark reality stands out – the pervasive
impact of poverty on people's ability to afford proper medical care. This stark inequality in access
to healthcare has left an indelible mark on my understanding of the broader challenges within our
society
Furthermore, the collaborative nature of nursing has become evident. As student nurses,
we are not isolated entities but integral parts of a larger healthcare team. Our ability to fulfill
proper practice relies on the support and cooperation of our peers, emphasizing the
interconnectedness of our roles in delivering effective healthcare.
In conclusion, my journey as a student nurse has unveiled the challenges of healthcare
accessibility, the profound impact of our efforts on patients in public hospitals, the imperative for
precision and competence in our duties, the collaborative nature of nursing practice, and the
significance of building and preserving positive relationships with those under our care. As I
continue on this path, I am committed to embodying these lessons and contributing to the well-
being of individuals in need.
FDAR:

Focus Data Action Response

Difficulty of Subjective: Independent: After doing the
Breathing “nahihirapan akong Position the Patient nursing intervention
huminga” in orthopneic or high the patients shows
fowler’s position relief as evidence of
(-) restlessness and
Objective: able to sleep
Restless Position the Patient in RR- 23
RR- 35bpm Orthopneic or High 02 Sat- 98%
Folwer’s position to (-) Tachypnea
BP- 70/40mmhg
promote respiration And goal was met
Tachycardia
Tachypnea Encourage the Patient
O2 Sat- 90% for deep breathing
exercise
Using accessory
muscle to breathe Provide Chest Physical
Pale appearance Therapy by back
tapping.

Dependent:

Oxygen support to 6
liter per minute via
Face Mask as ordered.

Nebulized the patient

with vasodilator as
ordered