ASSESSMENT
Impaired gas exchange related to
OBJECTIVE DATA:
Vital sign
Blood pressure: 130/80
Temperature: 37.5
Pulse rate: 89 BPM
Respiratory rate: 30 BPM
O2 saturation: 85
- The patient Use of
accessory muscle in
breathing
- Patient experienced
tachypnea
- Positive Barrel chest
SUBJECTIVE DATA:
“Nahihirapan ako himinga, at
pagumubo naman ako may
kasamang plema” as verbalized by
the patient
DIAGNOSIS
SHORT TERM GOAL:
obstruction of airway as evidence
by shortness of breath, use of
accessory muscle, and positive
barrel chest
PLANNING INTERVENTION
After 30 minutes of nursing
intervention the client
 Will be able to decreased
respiratory rate within the
normal rage.
.
 Will be able to maintain
normal vital signs.
 Will show relief in
breathing without the use
of his accessory muscle.
LONG TERM GOAL:
After 1 hours of nursing
intervention the client will be able
to
 Establish a normal and
effective respiratory
breathing.
 Demonstrates the
breathing coughing
exercise/technique
 Maintain normal
respiratory pattern
especially respiratory rate
within 16- 20 bpm.
 Maintain normal lung
function
RATIONALE
INDEPENDENT: INDEPENDENT:
1. Elevate the head of the
bed, assist the patient to
assume a position to ease
work of breathing. Include
periods of time in a prone
position as tolerated.
Encourage deep-slow or
pursed-lip breathing as
individually needed or
tolerated.
2. Assess and routinely
monitor skin and mucous
membrane color.
3. Assess and record
respiratory rate, depth.
Note the use of accessory
muscles, pursed-lip
breathing, inability to
speak or converse
edition g.508)
4. Encourage frequent
positioning changes and
After 30 minutes of nursing
 Oxygen delivery may be
improved by upright
position and breathing
exercises to decrease
airway collapse, dyspnea,
and work of breathing. Use
of prone position to
increase Pao2
Black, J. M., & Hawks, J. H.
(2009). Medical-surgical
nursing: Clinical
management for positive
outcomes (Vol. 1)
 Cyanosis may be
peripheral (noted in nail
beds) or central (noted
around lips/or earlobes).
Duskiness and central
cyanosis indicate advanced
hypoxemia
(Fundamentals of Nursing 7th
edition g.856.)
 Useful in evaluating the
degree of respiratory
distress or chronicity of the
disease process.
(Fundamentals of Nursing 7th
 To stimulate respiratory
Evaluation
intervention the client been able to
 Decreased his respiratory
rate in to 15 cpm.
 Normal vital signs are
maintained.
 Ventilate without the use of
accessory muscle.
Long Term:
After 1 hours of nursing
intervention, the patient will be
able to:
 Maintain an effective
breathing pattern as
evidenced by relaxed
breathing at, normal rate
(12-20 cycle per minute)
 Demonstrated the
breathing coughing
exercise/technique
 Acquired normal vital
signs are specially the
respiratory rate.
 Maintained his normal lung
function.
.
 deep- breathing coughing
exercise.
edition g.903)
DEPENDENT: DEPENDENT:
1. administer medications
such as bronchodilators
and mucolytic agents
2. Administration of oxygen
therapy as prescribed by
the physician.
COLLABORATIVE:
COLLABORATIVE:
1. .Coordinate with a
respiratory therapist for
chest physiotherapy and
nebulizer management as
indicated
function and to maintain
blood circulation, for
breathing exercise facilitate
lung aeration, to prevent
atelectasis and pneumonia.
(Fundamentals of Nursing 7th
 To promote pharmacologic
regimen(FUNDA Potter
Perry 9th edition pg. 892)
 Increasing humidity of
inspired air will reduce
thickness of secretions and
aid their removal.
(FUNDA Potter Perry
9th edition pg. 900)
 Consultants may be helpful
in ensuring that proper
treatments are met.
Fedorovich C; Littleton
MT. Chest
physiotherapy:
Evaluating the
effectiveness. Dimensions
of Critical Care Nursing