BUKIDNON STATE UNIVERSITY

FORTICH ST. SAYRE HIGHWAY,

MALAYBALAY CITY, BUKIDNON

Name of Client: Kate Carbonel

NURSING CARE PLAN

Date Formulated: March 2, 2022

Problem 1 (PE Format): Impaired gas exchange related to dyspnea as evidenced by difficulty of breathing
Level of Prioritization: High priority
Cause Analysis:  Growing uterus pushing upward on the lungs, and hormonal increases. Pregnancy dyspnea is usually harmless. However, in some cases, more serious
pregnancy complications can lead to difficulty breathing.
Goals: The patient will maintain effective breathing patterns.
CUES DESIRED OUTCOMES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short term: Independent:  In this nursing diagnosis, Short term:
 Patient verbalized that she  Patient will indicate verbal  Auscultate breath sounds, ventilator effort is insufficient Goal met. Patient is able to
is experiencing difficulty feelings of relief when note areas of to deliver enough oxygen or breathe without difficulty.
of breathing. breathing decreased/adventitious breath to get rid of sufficient
 Client is also apprehensive sounds as well as fremitus. amounts of carbon dioxide.

 A decreased level of
Objective: Long term:  Assess level of consciousness
Dyspnea consciousness can be an
 The patient will be able to and mentation changes.
Pale breathe without difficulty, indirect measurement of Long term:
Looks a bit apprehensive and will maintain normal impaired oxygenation, but it Goal met. Patient maintain
Fatigue breathing pattern. also impairs one’s ability to effective and normal breathing
protect the airway, pattern.
 Encourage frequent position potentially further adversely
changes and deep-breathing affecting oxygenation.
and coughing exercises.
 This promotes optimal chest
 Encourage adequate rest and expansion, mobilization of
limit activities to within client secretions, and oxygen
tolerance. Promote a calm, diffusion
restful environment.
 This helps limit oxygen needs

Reference: Student’s Name and Signature: Ralph Jules A. Simbo


 Provide airway adjuncts and
suction, as indicated,
Collaborative:
 Coordinate to dietitian and
Other medical physicians.
Reference:
and consumption
 To clear or maintain open
airway, when client is unable
to clear secretions,or to
improve gas diffusion when
client is showing desaturation
of oxygen by oximetry or
ABGs..
Student’s Name and Signature: Ralph Jules A. Simbo