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Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

1. Assessed 1. To assess patient

respiratory rate, condition
Subjective data: Impaired gas Short term goals: depth, use of The goals and
exchange r/t the accessory muscle objectives have been
“Iyak po ng iyak. destruction of After the nursing partially met by the
Hindi nakakahinga.” alveoli aeb DOB interventions during end of the nursing
as verbalized by the the shift the patient intervention as
mother will be able to: 2. Elevate head of the 2. To maintain evidenced by:
bed/position pt. airway
Objective data: 1. Verbalize
Short term goals:
understanding of
- c complaints of causative factors 3. Encourage 3. Promote optimal 1. “Kaya nahihirapan
DOB frequent position chest expansion huminga ang aking
changes and deep and drainage of anak dahil hindi
- symmetrical
breathing exercise secretion maayos ang supply
Long term goal: ng oxygen sa
- c nasal flaring
kanyang baga dahil
After 3 days of the
- (+) crackles sa madaming
nursing intervention Maintain adequate For mobilization
4. 4. plema.” as
- RR: 50 the patient will be I/O of secretions verbalized by
able to: mother
- c yellow sputum

- pale 5. Encourage 5. Helps limit

1. Demonstrate adequate rest and oxygen
- appears weak improved limit activities to needs/consumpti Long term goal:
ventilation and within pt. on
- irritable 1. Pt. exhibit absence
adequate tolerance
of symptoms of
respiratory distress
6. Keep environment 6. To reduce irritant aeb no pain, (-)
nasal flaring, (-)
allergen/pollutant effect of dust
crackles, no longer
free and chemicals
on airway