ASSESSMENT NURSING PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Risk for ineffective The client’s vital Monitor respiratory Respiratory rate and Patient’s vital signs are
“I’m having a hard time breathing pattern signs will be within rate and depth by rhythm changes are within normal.
breathing.” related to normal range after listening to lung early warning signs of P: 102 bpm
respiratory changes nursing sounds. impending respiratory RR: 21
Objective: during pregnancy as interventions and difficulties. SpO2: 97% (pulse
P: 130 bpm evidenced by oxygen therapy for 2 oximeter)
RR: 30 hypoxia. hours. Monitor patient’s To check the patient’s
SpO2: 87% (pulse vital signs. reaction to the Patient was able to
oximeter) Patient’s signs of interventions given. properly breath after
hypoxia are reduced the oxygen therapy.
+Dyspnea or eliminated. Attach oxygen Humidity prevents
+Anxious delivery device drying of nasal and Patient was now alert
+Pallor Patient’s vital signs properly to the oral mucous and stable.
+Altered concentration remain stable or oxygen tubing and membranes and
return to baseline. attach end of airway secretions.
tubing to Ensures correct O2
Patient’s work of humidified oxygen delivery.
breathing decreases. source adjusted to
prescribed flow
Patient experiences rate. For the
increased lung patient’s condition
expansion. nasal cannula (2-3
L/min).
Patient’s LOC
returns to baseline. Apply oxygen Directs flow of oxygen
device: Place the into patient’s upper
SpO2 returns to two tips of the respiratory tract.
normal or baseline. cannula into Patient is more likely
Patient’s nares and patient’s nares. If to keep device in
nasal mucosa remain the tips are curved, place if it fits
intact. they should point comfortably.
downward inside
the nostrils. Then
loop the cannula
tubing up and over
patient’s ears.
Adjust the lanyard
so the cannula fits
snugly but not too
tightly

Maintain sufficient Allows patient to turn

slack on oxygen head without causing
tubing and secure mask to shift position
to patient’s clothes or dislodge nasal
cannula.

Observe for proper Ensures patency of

function of oxygen delivery device and
delivery device accuracy of prescribed
oxygen flow rate.

Verify setting on Ensures delivery of

flowmeter and prescribed oxygen
oxygen source for therapy in conjunction
proper setup and with specific
prescribed flow cannula/mask
rate.