Assessment Nsg. Diagnosis E.O.
C Planning Implementation Rational Evaluation
Subjective data Ineffective The patient - Assess the - Breathing pattern - - To know base
Patient relative is airway will have breathing pattern of patient is line
telling that he is clearance R/T improved of patient assessed, he is information
unable to breath Pulmonary airway - Check vital signs of having dyspnea
normally since 2 edema and clearance, patient - Vital signs are - To know base
days . line
excessive as respiratory rate is
information
secretions evidenced 28/min, B.P 130/90
Objective data by effective mm of h.g, Pulse
- Patient is having coughing rare is 90/min.
difficulty in techniques - Perform chest - chest - To fecilitate
breathing and patent physiotherapy physiotherapy secreations
- Respiratory rate airway. Performed
is 28// min - Asses the client’s - Assessed the client’s - It helps in
- On inspection evaluation of
breath sound breath sound
coughing
there is rapid chest before and after before and after
effectiveness
movement coughing episode. coughing
bilaterally episode
- Administer O2 if - done - To facilitate
needed easy
respiration
- Teach the patient - done
deep breathing and
coughing exercises
Assessment Nsg. Diagnosis E.O.C Planning Implementation Rational Evaluatio
n
Subjective data Impaired gas The patient - Monitor the - Done - - To know base line
Patient relative is exchange R/T will maintain patient’s respiratory information
complaining about decreased adequate gas respiratory rate rate is 30/min
difficulty in ventilation exchange as and pattern.
- To know normal
breathing. and evidenced by
gas exchange
Pulmonary ABG values. - Monitor ABG
Objective data - ABG values
edema
are
- Respiratory rate
Po2- 76
is 28// min - - To facilitate easy
Pco2- 52 respiration
- On inspection - Administer low
pH- 7.44 -
there is rapid chest flow O2 therapy
- To facilitate easy
movement (1-3 lit/min) respiration
- Done
bilaterally
- ABG Values are - Give high fowler’s
Po2- 76 position to - To facilitate easy
Pco2- 52 patient - Done respiration
pH- 7.44
- Do suctioning if
- done
needed
Evaluatio
Assessment Nsg. Diagnosis E.O.C Planning Implementation Rational n
Subjective data
Patient relatives Sleep pattern The patient - Assess the sleep - To know
- Done
baseline
explaining that disturbance will report pattern of patient
information
patient is unable R/T dyspnea feeling - Promote - Done
to sleep because adequately relaxation by - -To promote
of respiratory Adequate
rested providing darken
sleep
problem. envirnment - Done
- Provide calm and - -To promote
Objective data - Done Adequate
quite
sleep
- Patient is environment - -To promote
looking drowsy - Advised family Adequate
and restless members to avoid sleep
- Done
- Patient is on day sleep of - To prevent
O2 therapy patient any obstacles
- Give comfortable during sleep
position to
patient
Assessment Nsg. Diagnosis E.O.C Planning Implementation Rational Evaluatio
n
Subjective data Impaired gas The patient - Monitor the - Done - - To know base line
Patient relative is exchange R/T will maintain patient’s respiratory information
complaining about decreased adequate gas respiratory rate rate is 30/min
difficulty in ventilation exchange as and pattern.
- To know normal
breathing. and evidenced by
gas exchange
Pulmonary ABG values. - Monitor ABG
Objective data - ABG values
edema
are
- Respiratory rate
Po2- 76
is 28// min - - To facilitate easy
Pco2- 52 respiration
- On inspection - Administer low
pH- 7.44 -
there is rapid chest flow O2 therapy
- To facilitate easy
movement (1-3 lit/min) respiration
- Done
bilaterally
- ABG Values are - Give high fowler’s
Po2- 76 position to - To facilitate easy
Pco2- 52 patient - Done respiration
pH- 7.44
- Do suctioning if
- done
needed
Assessment Nsg. Diagnosis E.O.C Planning Implementation Rational Evaluatio
n
Subjective data Anxiety R/T The patient - Advise family
- Done - To minimize
Patient relatives breathing will express members be with anxiety
explaining that difficulty and an increase in the patient during
patient is very fear of psychological acute episodes of
anxious because of suffocation comfort and breathing
respiratory demonstrate difficulty
problem. use of - Provide calm and
- Done - To minimize
effective quite irritation
Objective data coping environment
- Patient is mechanism - Encourage the - Done - To cope up
with
looking very use of breathing breathing
restless and retraining and problem
fearful relaxation
- Patient is on technique
O2 therapy - Give anti-anxiety
- Done - To minimize
drug if ordered anxiety
NURSES NOTES
DATE MEDICATION DIET TIME NURSING OBSERVATION AND INTERVENTION SIGN
12/12/09 T- Cordarone 200m.g 8a.m - Patient is sleeping on his bed in semifowler’s
OD position, bed making done bed is looking
tidy and clean.
T- Clopigree 75 m.g
OD
- Patient is on O2 therapy, looking restless and
9 a.m
T-Lasix 40m.g B.D anxious
T-Aatron- 1m.g TDS 10a.m - Vital signs are checked
B.P – 130/90 mm of H.g
T- Losar 25 m.g OD Pulse – 86/ min
Resp – 24/ min
INJ- Novarapid SC
11 a.m - Medications given to patient
12 p.m - Advised given to family members to remain
with patient
- Psychological support given to patient and
2p.m
family members
NURSES NOTES
DATE MEDICATION DIET TIME NURSING OBSERVATION AND INTERVENTION SIGN
13/12/09 T- Cordarone 200m.g 8a.m - Patient is sleeping on his bed in semifowler’s
OD position, bed making done bed is looking
tidy and clean.
T- Clopigree 75 m.g
OD
- Patient is on O2 therapy, looking restless and
9 a.m
T-Lasix 40m.g B.D anxious
T-Aatron- 1m.g TDS 10a.m - Vital signs are checked
B.P – 130/90 mm of H.g
T- Losar 25 m.g OD Pulse – 82/ min
Resp – 24/ min
INJ- Novarapid SC
11 a.m - Medications given to patient
12 p.m - Advised given to family members to remain
with patient
- Psychological support given to patient and
2p.m
family members
NURSES NOTES
DATE MEDICATION DIET TIME NURSING OBSERVATION AND INTERVENTION SIGN
14/12/09 T- Cordarone 200m.g 8a.m - Patient is sleeping on his bed in semifowler’s
OD position, bed making done bed is looking
tidy and clean.
T- Clopigree 75 m.g
OD
- Patient is on O2 therapy, looking
9 a.m
T-Lasix 40m.g B.D comfortable and relaxed.
T-Aatron- 1m.g TDS 10a.m - Vital signs are checked
B.P – 120/90 mm of H.g
T- Losar 25 m.g OD Pulse – 84/ min
Resp – 24/ min
INJ- Novarapid SC
11 a.m
- Medications given to patient
12 p.m
- Advised given to family members to remain
with patient
2p.m - Psychological support given to patient and
family members
