Assessment Diagnosis Planning Intervention Evaluation

SUBJECTIVE: Impaired gas Short term: NDEPENDENT: Short term:

exchange related  Note
“Nakakaranas ako to altered oxygen respiratory
ng hingal sa supply. rate, depth,
paghinga at Long term: and ease of Long term:
panankit ng After 8 hours of respirations. After 8 hours of
dibdib” (Lately, I've nursing Observe for nursing
been experiencing intervention the the use of intervention the
shortness of breath patient will patient was able
accessory
and chest pains) as
demonstrate muscles, to
verbalized by the improved pursed lip demonstrate
patient ventilation and improved
breathing,
adequate changes in ventilation and
oxygenation of skin or adequate
OBJECTIVE: tissues by ABGs mucous oxygenation of
within patient’s membrane tissues by ABGs
 Restlessne normal range. color. within patient’s
ss normal range.
 Cyanosis  Auscultate
 Changes lungs for air
in movement and
mentation abnormal
breath sounds.
 V/S taken
as follows  Investigate
restlessness
T: 37.1 ˚C and changes
P: 101 in mentation or
R: 25 level of
BP: 120/ 80 consciousness

 Maintain
patent airway
by positioning,
suctioning,
use of airway
adjuncts.

 Reposition
frequently,
placing patient
in sitting
positions and
supine to side
positions.

 Avoid
positioning
patient with a
pneumonecto
my on the
operative side.
Favor the
“good lung
 down”
position.

 Encourage or
assist with
deep
breathing
exercises and
pursed-lip
breathing as
appropriate.

DEPENDENT:
 Administer
supplemental
oxygen via
nasal cannula,
partial
rebreathing
mask, or high
humidity face
mask as
indicated.
 Monitor graph
of ABGs, pulse
oximetry
readings.