ASSESSMEN NURSING T DIAGNOSIS

NURSING GOAL

INTERVENT RATIONAL IONS E

OUTCOME CRITERIA

Subjective: mag lisod ug ginhawa akong anak as verbalized by the mother of the patient Objective: - Patient is irritable - nasal flaring noted - diaphoresis - dyspnea with the VS of: TPR-

Impaired gas exchange related to inflammation of the alveoli

After 6 hours of nursing interventions the patient will demonstrate ease in breathing.

1. Monitor 1. To establish vital signs and baseline data. assess patients conditions. 2. Determine adequacy of 2.Auscultate gas exchange lungs for and detect crackles , areas of consolidation consolidation and pleural and pleural friction rub. friction rub. 3. This signs may indicate hypoxia.

The patient demonstrate ease in breathing after 6 hours of thorough intervention as evidenced by regular breathing pattern with the RR of

3. Assess LOC, distress 4. Determine and irritability. circulatory 4. adequacy, Observe skin which is color and necessary for capillary refill. gas exchange to tissues. 5. Rest prevents tissue oxygen demand and enhances tissue oxygen perfusion.

5. Encourage rest.

6. To facilitate lung 6. Encourage expansion to elevated HOB. enhance breathing. 7. Perform ches t physiotherapy after nebulization. 7. To dislodge the secretions, for easy expectoration

8. Administer oxygen as ordered.

8. Improves gas-exchange decrease work of breathing.