ASSESSMENT EXPLANATION GOALS AND INTERVENTION RATIONALE EVALUATION

OF THE OBJECTIVES
PROBLEM
Subjective:  impaired Gas Short Term:  Monitor  “Increased STO:
 “ubo ako Exchange respiratory rate, respiratory rate, use Goal met,
nang ubo related to The client will depth , and of accessory The client
lalo na pag ventilation demonstrate effort, including muscles, nasal Demonstrated
gabi kaya perfusion improved use of accessory flaring, abdominal improved
sumasakit na imbalance ventilation, muscles, nasal breathing, and a ventilation,
din ung evidenced by adequate flaring and look of panic in the adequate
dibdib ko” dyspnea with oxygenation abnormal client’s eyes may be oxygenation
exertion, by the end of breathing seen with hypoxia.”
Objective: tachypnea, the shift. patterns. (Ackley, 2006, LTO:
 awake, changes in p.558) Goal partially
 ambulatory, mentation, met,
 responsive, irritability, Long Term: The client has
 oriented to tachycardia,  Auscultate  “In severe improved
time, place, hypoxia, The client breath sounds exacerbations, breathing but
and person. hypercapnia will be free of every 1-2 hrs or lungs sounds may still show
 becomes respiratory prn and be alert be diminished or distress when
noticeably  decreased distress when for crackles and distant with air walking
breathless oxygen- walking after wheezes that trapping.” (Ackley,
during carrying rendering could indicate 2006, p.558)
exertion capacity of appropriate airway
blood, nursing obstruction and
Vital signs: altered intervention for increase the
BP-140/80mmH oxygen 1 week difficult
SP02: 92 %, supply, breathing.
Temperature: alveolar-
36.1 C, RR: 22, capillary
HR: 98 bpm membrane  Monitor oxygen  “An oxygen
changes. saturation saturation of less
Nursing Dx: continuously than 90% (normal:
Impaired gas using pulse 95 to 100%)
exchange r/t oximetry. indicates significant
ventilation- Monitor ABG’s oxygenation
perfusion labs values if problems.” (Ackley,
imbalance available and 2006, p.558)
chest X-rays

 Position the  “Research done on

client in semi- clients on a
Fowler’s ventilator
position, with an demonstrated that
upright posture being in a 45 degree
at 45 degrees if upright position
possible. increased
oxygenation and
ventilation.
Research on
healthy subjects
demonstrated that
sitting upright
resulted in higher
tidal volumes and
minute ventilation
versus sitting in a
slumped posture.”
(Ackley, 2006,
p.558)
 Administer and  “Oxygen has been
assess response shown to correct
to oxygen for hypoxemia , which
respiratory can be caused by
distress. Provide retained secretions).
humidified (Ackley, 2006,
oxygen through p.167) The goal of
an appropriate inpatient oxygen
device ( nasal therapy for a client
canula or Venturi with asthma is to
mask per keep an oxygen
physician order). greater than 95% to
maintain cellular
oxygenation.”
(Ackley, 2006,
p.558)
ASSESSMENT EXPLANATION GOALS AND INTERVENTION RATIONALE EVALUATION
OF THE OBJECTIVES
PROBLEM
Subjective: Short Term:  Check for  Sufficient fluid STO:
 “ubo ako optimal fluid intake maintains
nang ubo the client will be able balance. adequate filling Goal met, the
lalo na pag to identify necessary Administer pressures and client was able
gabi kaya lifestyle changes and IV fluids as optimizes cardiac to identify
sumasakit factors that improve ordered. output needed for necessary
na din ung circulation by the end tissue perfusion. lifestyle
dibdib ko” of the shift. changes and
factors that
Objective:  Maintain  This ensures improve
 awake, Long Term: optimal adequate perfusion circulation
 ambulatory, cardiac of vital organs.
 responsive, After rendering output.
 oriented to appropriate nursing LTO:
time, place, intervention for 7
and person. days, the client will  educate  Orthostatic Goal partially
 becomes be able to exhibit methods to hypotension results met, the client
noticeably growing tolerance to decrease in temporary was able
breathless activity and will show dizziness, decreased cerebral to exhibit
during no further such as perfusion. progress in
exertion worsening/repetition remaining tolerance
of deficits seated for towards
Vital signs: several activities and
BP-140/80mmH minutes has shown
SP02: 92 %, before improvements
Temperature: standing, in his
36.1 C, RR: 22, flexing feet repetition of
HR: 98 bpm upward deficits
 several
Nursing Dx: times while
Risk for seated,
ineffective rising slowly,
cerebral tissue sitting down
perfusion immediately
if feeling
dizzy, and
trying to
have
someone
present
when
standing.
 Review trend in
 Check level of
mental consciousness
status; (LOC) and
perform a possibility for
neurological increased ICP and
examination. is helpful in
deciding location,
extent and
development/resolu
tion or central
nervous system
(CNS) damage.

 These will further

 Avoid reduce cerebral
 measures blood flow.
that may
trigger
increased
ICP such as
coughing,
vomiting,
straining at
stool, neck in
flexion, head
flat, or
bearing
down.
 Control
 Control environmental
environment temperature as
al necessary. Perform
temperature tepid sponge bath
as when fever occurs.
necessary.
Perform
tepid sponge
bath when
fever occurs.
 Constant activity
 Provide rest can further increase
periods ICP by creating a
between cumulative
care stimulant effect.
activities and
prevent
 duration of
procedures.
 Decreased cerebral
 Reorient to blood flow or
environment cerebral edema
as needed. may result in
changes in the
LOC.