Assessment Nursing Planning Implementation Evaluation

Diagnosis
Objective: Ineffective Patient will - Monitor Patient will
breathing demonstrate and record demonstrate pursed-
PR- 60-74 pattern r/t as pursed-lip VS lip breathing and
BP- 130/90 aeb dyspnea breathing and - Auscultate diaphragmatic
RR-32-33 diaphragmatic breath breathing
breathing. sounds
- Facial and Patient will manifest
grimacin Patient will assess. signs of decreased
g manifest - Encourage respiratory effort
signs of deep AEB absence of
- Fatigue decreased breathing dyspnea.
respiratory and
- Restless effort AEB coughing
ness absence of exercise.
dyspnea - Encourage
increase in
fluid intake

Assessment Nursing Planning Implementation Evaluation

Diagnosis
Subjective: impaired Clients O2 Nursing student will Nursing student
gas saturation will make hourly rounds checked clients O2
- Mejo exchange r/t remain higher to ensure that saturation which was
nahihirap aeb spo2 than 90% clients nasal 95% with 3L
an po 92% throughout the cannula is in proper O2. Nursing student
ako shift. position. then readjusted
huminga clients nasal cannula
as Maintain client Assess clients and checked
verbalize comfort by saturation levels 15
breathing.
d by the assessing ease min.
patient of breathing
every 4 Use pulse/oximeter
Objective: hrs. Client will to check clients O2
report minimal saturation 2x during
- Irritable discomfort in the shift
- Restless breathing
- O2 sat- efforts.
92%
- RR- 32-
33
 Assessment Nursing Planning Implementation Evaluation
Diagnosis

Assess for signs ineffective Patient Assess for probable Patient will identify the
of decreased peripheral identifies contributing factors factors that improved
tissue perfusion. tissue related to
perfusion factors that temporarily impaired circulation.
aeb 4-5 arterial blood flow.
seconds improve
blanch test Submit patient to Patient identified the
circulation.
diagnostic testing as
indicated. necessary lifestyle
Patient changes.
Check for optimal
identifies fluid balance.
Administer IV fluids Patient shows no
necessary as ordered.
further
lifestyle
worsening/repetition of
changes.
deficits
Patient exhibits
growing
tolerance to
activity.