F: Difficulty of Breathing

D: “Nahihirapan akong huminga” as verbalized by the patient

 Uses of accessory muscle

 Nasal flaring
 Intercostal space extraction
 Wheezing upon ausculatation

Vital Signs

 BP: 120/90
 RR: 30 bpm
 PR: 79 bpm
 TEMP: 36.9 0 C

A: Vital signs taken and recorded

 Encouraged fluid intake (1-2 L/day)

 Encouraged Deep Breathing Exercise
 Chest physiotherapy 30 minutes before meal
 Reposition the patient to semi/high fowler’s position every 2 hours
 PNSS 600 cc regulated @ 22-23 gtts.
 Meds given as prescribed by the physician.

R: The patient is able to breath normally ranges 16 to 20 bpm

 The patient relieved and able to sleep with a minimum of 8 hours
 Continue monitoring.