ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

S>”Naninikip ang Ineffective Short Term: Independent: Goal was met,

dibdib ko,masakit at breathing After 2-5 minutes -Auscultate chest -To evaluate presence / character After 3 minutes of nursing
hindi ako pattern related of nursing of breath sounds/secretions intervention the client was able
masyadong to chest pain intervention the - Elevate HOB or have client - To promote to:
makahinga”, as as evidenced client will be able sit up in chair, as appropriate physiological/psychological ease
verbalized by the by a to: or maximal inspiration.
client. respiratory -Stress importance of good - To maximize respiratory effort.
rate of 34cpm. -Establish a posture and effective use of -Establish a normal/effective
normal/effective accessory muscles respiratory pattern as evidenced
respiratory pattern by absence of signs and
as evidenced by Dependent: -for management of underlying symptoms of hypoxia with
O> PR-112bpm absence of signs - Administer oxygen at lower condition or respiratory distress. ABGs within client’s normal
RR-34cpm and symptoms of concentration indicated and range.
Use of accessory hypoxia with ABGs prescribed respiratory
Muscles within client’s medication -to verify
Nasal Flaring normal range. maintenance/improvement in O2
-Monitor Pulse Oximetry as saturation
indicated