NURSING CARE PLAN

Identified Problem: dusky skin discoloration

Nursing Diagnosis: Altered tissue perfusion related to impaired transport of oxygen across alveolar capillary membranes evidenced by dusky skin discoloration, dry cough and DOB

CUES OBJ ECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective:

Luspad siya unya galisod ug
ginhawa a verbalized by
patients SO

















Objective:
-nasal flaring
-chest retraction upon breathing
-tachypnea
- auscultated bilateral wheezing
Short term objectives:
After 8 hours of duty
patient will be able to
verbalized understanding
of condition















Long term objectives:
After 3 days of duty
patient will be able to
increase tissue perfusion
1. Monitor vital signs every 4 hours and
as necessary
2. Monitor intake and output
3. Assess lower extremities, CRT,
noting skin texture, ulcerations
4. Weigh daily
5. Encourage quiet, restful atmosphere
6. Elevate HOB

1. To have a baseline data and for
subsequent evaluation
2. To monitor for fluid and
electrolytes imbalances
3. To assess tissue oxygen
demands
4. To assess for malnutrition and
metabolic demands
5. To conserve energy/lowers
tissue oxygen demands
6. To promote circulation
Short term:

After 4 hours duty patient was not
able to verbalized understanding
of condition. Goal was not met


















Long term:
After 3 days of duty patient was
able to increased and maintain
oxygen demands. Goal was met