PRIORITY PROBLEM #: Nursing Diagnosis: Ineffective tissue perfusion related to impaired transport of oxygen across alveolar membrane Date

of Assessment: August 20, 2013 Assessment Subjective Cues: verbalized. Objective Cues:  RR – 61cpm  Use of accessory muscles  Weakness noted  Cold and clammy skin  O2 Sat of 81% Goals and Objectives Short term: After 8 hours of nursing interventions, the patient will be able to participate in therapeutic regimen and to increase skin temperature. Long term: After 4 days of nursing interventions, the patient would be able to demonstrate behaviors to improve circulation. Nursing Interventions and Rationale Independent: 1. Elevated head of bed especially on sleep time R – To promote circulation and venous drainage. 2. Encouraged relaxation. R – Decreases tissue oxygen demands. 3. Encouraged warm dressings and preventing exposure to colds. R – To retain heat more efficiently. 4. Assisted and instructed to change position at timed intervals, rather than using presence of pain as signal to change positions. R – To facilitate lung tissue circulation “Medjo sakit akong dughan kung mu-ginhawa ko,” as

Collaborative/Dependent: 1. Administered prescribed medications as ordered.

Evaluation Short term: After 8 hours of nursing interventions. . goals partially met. Long term: Goals not met. patient was still in respiratory distress. Administered supplemental oxygen via nasal cannula as ordered to maximize oxygen available for cellular uptake. Patient participated in therapeutic regimen but skin is still not warm to touch.2. After 4 days of rendering nursing interventions.

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