b.

Actual Nursing Care Plan CUES Subjective “galisod man ko ug ginhawa”, as verbalized by the patient Objective  Nasal flaring noted  Irritability as noted  Tachypne a-RR: 55 cpm as noted Nursing Diagnosis Ineffective breathing pattern related to hyperventilation as evidenced by tachypnea with RR of 55 cpm

Goals & Objectives

Interventions

Rationale

Evaluation At the end of 1 hour, goals were partially met since the patient was able to perform pursed-lip breathing but still in slightly ineffective breathing pattern.

At the end of30 INDEPENDENT: minutes to 1  Elevate head of the hour, client will bed and instruct to do be able to deep breathing breathe exercises. comfortably,  Maintain calm attitude with ability to while dealing with client performed & significant others. pursed-lip  Assess color of the skin breathing and and oral mucosa use of including the tongue. relaxation  Encourage client to use techniques. relaxation technique like diversional activities  Teach client and significant others with the contributing factors of the condition. COLLABORATIVE:  Provide oxygen inhalation as ordered. - O2 inhalatin @ 2 LPM via nasal canula  Administer medication as prescribed. terbutaline (Bricanyl) syrup 5 ml TID PO

- Promotes ease of maximal inspiration, allowing optimal lung expansion - This will limit client’s level of anxiety. - To determine cyanosis - Relaxation minimizes oxygen demand - It helps client to be aware of the condition at it reduces the risk for reoccurrence of ineffective breathing episodes. - To increase oxygenation, improve ventilation, and reduce dyspnea. - Aids in muscle contractility thus decreasing cardiac output preventing cardiac overload.

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b. Actual Nursing Care Plan CUES Subjective “gakalipong ko pag mubangon ko sa akong higdaanan” , as verbalized by the patient. Objective Nursing Diagnosis

Goals & Objectives

Interventions

Rationale

Evaluation At the end of 30 minutes to 1 hour, goals were partially met since the patient was able to establish improved ventilation but still tachypneic with present RR of 47cpm

Impaired  slightly weak gas as noted exchange  restless on appearance related to  pale and altered delivery of dusky skin color noted oxygen  RR: 55 cpm  nasal flaring noted  diaphoresis noted  dizziness as noted

At the end INDEPENDENT: of 30 minutes to 1  Elevate head of the bed at ◦ hour, client 45 will be able  Encourage patient to do to deep breathing exercises. demonstrate  Monitor skin and mucous improvemen membrane color. t of ventilation  Encourage adequate rest and and limit activities within adequate client’s tolerance. oxygenation  Monitor level of . consciousness or mental status. COLLABORATIVE:  Provide oxygen inhalation as ordered. -O2 inhalation @ 2 LPM via nasal canula  Give medication as prescribed. - terbutaline (Bricanyl) syrup 5ml TID P.O  Monitor O2 saturation using pulse oximeter

- Elevation assist airway patency - Facilitates optimal lung expansion. - Duskiness and cyanosis indicate advanced hypoxemia - It helps in limiting oxygen need or consumption. - Indicative of cerebral dysfunction.

- To increase oxygenation, improve ventilation, and decrease dyspnea. - To cause bronchodilation. - O2 saturation of less than 90% indicates significant oxygenation problems.

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b. Actual Nursing Care Plan CUES Subjective NO CUES Objective  Slow capillary refill CRT:3-4 seconds as noted  Nasal flaring noted  Tachypn ea RR: 55 cpm as noted Nursing Diagnosis Ineffective tissue perfusion related to decreased oxygen pumped by the heart

Goals & Objectives

Interventions

Rationale

Evaluation At the end of 1 hour, goals were partially met since the patient shows improve tissue perfusion but with slow capillary refill time of 3 seconds.

At the end INDEPENDENT: of 30  Note baseline data minutes-1 like vital signs and mental hour, patient status. will be able  Encourage quiet, to show sign restful atmosphere. of adequate tissue perfusion  Caution client to with good avoid activities that capillary increase cardiac work refill time load.  Encourage client to ambulate within tolerance.  Monitor respiration including work of breathing. COLLABORATIVE:  Provide oxygen inhalation as ordered. -O2 inhalation@ 2 LPM via nasal canula  Administer medication as prescribed, -Dopamine ;1 amp + 200 cc D5W via yringe pump -Dobutamine ;20 ml IVTT

- To determine any unusualities. - It will conserve energy and lowers oxygen demands of tissues. - To prevent potential health problems from occurring. - To promote blood circulation. - Failure of the heart to pump can lead to respiratory distress.

- Oxygen therapy helps decrease dyspnea and improve ventilation. - To increase contractility which will lead to increase cardiac output

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