Need/Nursing Scientific Nursing Value

Objective Rationale Evaluation

Diagnosis/Cues Analysis Intervention Integration
Need: After 6-8 Independent: After 6-8 Sense of
Physiologic need Due to fluid excess hours of hours of responsibility
volume in the lung nursing • Encouraged deep • Opening up all the way to the nursing and
Nursing Diagnosis: and intervention, breathing bases increases surface area intervention, accountability
Impaired gas exudates crosses the patient techniques to open for oxygen exchange. the patient in whatever
exchange related to the will be able up lung bases was able to: actions being
fluid overload as permeable to: increase oxygen done.
manifested by membrane exchange in blood. a. Patient
requirements of of the pleurae a. Patient • Taught patient the • It is important that patient be was able to Self-
oxygen causing will be able importance of deep involved in their return to breathe on confidence in
supplementation and it to accumulate in to breathe breathing. health and will increase room air interacting
shortness of breath this on room air compliance. without with the
with activity. membranous space. without • Auscultated breath • The presence of crackles or shortness of patient.
Instead of the lungs shortness of sounds, listening wheezes would indicate fluid breath by
Cues: being able to breath by for sounds of is filling her lungs: further discharge.
function discharge. crackles or exacerbation of fluid
Subjective cues: normally, these wheezes. overload.
“Maglisud ko ug fluids
ginhawa maam”, as inhibit the lungs to
verbalized by the expand • Positioned in semi- • Research indicates that keep
patient. anteroposteriorly fowler’s position. the head of the bed elevated
thus between a 30 – 45 degree
Objective cues: causing ineffective angle increases oxygenation
• Rapid, shallow breathing and gas exchange. (Ackley, B.
breathing & discomfort. J., Ladwig, G. B., 2008)
• Sodium restricted • Decreased amounts of sodium
• Adventitious diet. will reduce the amount of
breath sounds fluid retention which will help
noted (rhonchi, the underlying problem.
wheezes)
• Monitored intake • To see a negative balance to
• Restlessness and output confirm effectiveness of
volumes. diuretics and other therapies
• Dyspnea to reduce fluids.
• Weighted patient • This will show progress of
• Use of daily. fluid removal and help
accessory determine effectiveness of
muscles for treatments.
respiration Dependent:

• Administration of • This will help remove some