Assessment Nursing Diagnosis Planning Intervention Rationale Evalutation

Subjective: Impaired Gas Exchange After 8hrs of Nursing Independent: Independent: After 8hrs of Nursing
Related to respiratory Intervention the client will Intervention the client
The client’s chief alkalosis manifested by show signs of relief after 1. Monitor Vitals Signs 1. To monitor current was saw signs of relief
complaint is shortness of initial arterial blood gas pulmonary stress and ABG analysis condition of the client after pulmonary stress
breathing with pH 7.491, PCO2 27.6, (Shortness of breathing) (Shortness of breathing)
PO2 53.6, HCO3 20.6 2. Teach Patient to 2. To reduced excessive
Objective: and shortness of breath at brown CO2 release
breathing paper bag.
Sign and symptoms of 3. To control CO2 release
COPD 3. Perform
non-pharmachologic 4. To prevent
Initial arterial blood gas management such as hyperventilation
with pH 7.491, PCO2 27.6, such as purse lip
PO2 53.6, HCO3 20.6 breathing 5. To prevent further
Repiratory alkalosis severe conditions
4. Check for
environmental
factors such as
ventilation of the
room

5. Watch out for

complication

Benauro, Seth Michael Daniel

NCMB312 RLE BSN 3Y1-3S
Week 7 CHF- NCP
Assessment Nursing Diagnosis Planning Intervention Rationale Evalutation
Objective Decrease Cardiac output After 8hrs of Nursing Independent: Independent: After 8hrs of Nursing
The mitral valve is related valve stuctural Intervention the client will Intervention the client
abnormal in structure. changes as manifested by able demonstrate 1. Note heart sounds. 1. S1 and S2 may be Was able demonstrate
Mild mitral annular mitral valve is abnormal in adequate cardiac output 2. Monitor BP and vital weak because of adequate cardiac output
calcification is present. structure according to as evidenced by vital signs signs. diminished pumping as evidenced by vital signs
There is bilateral Echocardiogram within acceptable limits, 3. Assess for abnormal action. Gallop rhythms within acceptable limits,
thickening present. Trace dysrhythmias heart and lung sounds are common (S3and S4), dysrhythmias
mitral valve regurgitation absent/controlled, and no 4. Monitor oxygen produced as blood flows absent/controlled, and no
is present.according to symptoms of failure. saturation and ABGs. into noncompliant symptoms of failure.
Echocardiogram 5. Monitor results of chambers. Murmurs may
laboratory and diagnostic reflect valvular
tests. incompetence.
2. For further more
Dependent: evaluation
3. Allows detection of
Administer cardiac left-sided heart failure
glycoside agents, as that may occur with
ordered, for signs of left chronic renal failure
sided failure, and monitor patients due to fluid
for toxicity. volume excess as the
diseased kidneys are
unable to excrete water.
4. Provides information
regarding the heart’s
ability to perfuse distal
tissues with oxygenated
blood
5. Results of the test
provide clues to the
status of the disease and
response to treatments.

Dependent

Digitalis has a positive

isotropic effect on the
myocardium that
strengthens contractility,
thus improving cardiac
output.