Nursing Care Plan

Assessment Diagnosis Planning Intervention Evaluation

Subjective Impaired gas exchange Short term goal:  Assess health history After effective nursing
related to decrease and medical record intervention the patient
“naninikip na masakit pulmonary perfusion After 1 hour of nursing  Monitor patients vital was able to:
yung dibdib ko parang associated with the intervention the patient signs including oxygen
sinasaksak at nahihirapan obstruction of pulmonary will be able to report saturation level  Report alleviated
ako huminga” as the arterial blood flow by the alleviated pain and  Management of pain: pain and increased
patient verbalize embolus increase perfusion Give pain medication perfusion.
as prescribed  Maintained
Objective Long term goal:  Position the client: adequate gas
Head should be exchange as
 Restlessness After 4 days of nursing elevated evidence by
 Shortness of intervention the patient  Encourage position normal level of
breath and will be able to maintain changes every 2 hours oxygen saturation
stabbing chest optimal gas exchange as to improve ventilation of 95 % or higher
pain evidenced by normal level perfusion ratio
 Coughs produces of oxygen saturation of 95  Encourage adequate
bloody sputum % or higher rest and limit
 Tachycardia activities within client
 Pale in appearance tolerance this helps to
 Vital signs limit activities oxygen
Temp: 36.8°C needs and
PR: 115bpm consumption
RR: 26cpm  Encourage fluid intake
BP: 80/60 mmHg of 2L/day to decrease
O2 sat: 85 % blood viscosity
 Administer
supplementary
oxygen to support gas
exchange
Nursing Care Plan

 Administer
medication as needed
and prescribed by the
physician:
thrombolytics/
anticoagulants
 Relieved patient
anxiety: Encourage
the patient to talk
about fears and
concern to recent
situation