ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATIO RATIONALE EVALUATION

N
Subjective: Ineffective After 1hour of Independent Within 1 hour
breathing proper nursing of proper
“Nurse pattern related intervention, nursing
- Place the patient
nahihirapan to the patient will intervention,
to high-fowlers - To improve
akong accumulation be able to the patient
position, as expansion of
huminga” as of fluid in the maintain was able to
tolerated. lungs for the
stated by the lungs normal maintain
patient. patient to
breathing breathe normal
pattern as effectively. breathing
evidenced by pattern as
Objective: respiratory evidenced by
rate from 22 respiratory
 - crackles  cpm to 20 cpm rate from 28
- Administer 1-2 - To maintain cpm to 20
- Tachypnea Scientific LPM of oxygen via oxygenation at cpm.
Explanation: nasal cannula, as an acceptable
- mild appropriate. level, 1-2 liters
subcostal Ineffective of oxygen is
breathing Goal Met.
retractions considered
patterns can independent
Vital Signs lead to life- intervention.
are as threatening
follows:  circumstances
such as heart
failure, and
BP:
hypoxia leading - As it
140/90mmHg, 
to unimproved promotes more
oxygen effective
PR: 92 bpm,  - Assist the client in
saturation and breathing, and
vital signs. proper deep
RR: 28 or 22 airway
breathing exercises.
cpm,  management

Temp: 36.4'C
- Restrictive
clothing does
not allow
  diaphragm to
- Loosen tight move in a
clothing. normal, health
manner. This
restricts
oxygen intake.
 - Proper
ventilation
provides good
airflow.

- Provide proper
ventilation by
having not - To promote
overcrowded room, health and
with fan on.  prevent further
complications.

- Provide health
teachings like the
need of patient for
adequate rest, use
of relaxation and
breathing
techniques (like
pursed-lip
breathing), to place
on high-fowlers
position, as
appropriate.

Dependent

- Increase
administration of - To provide
oxygen (3-4 LPM) adequate
via NC, as doctor’s oxygen within
order. the target
range.

- Administer
Furosemide 40mg
- Furosemide
IVP q 6, as ordered
acts as
by the physician.
diuretics that
reduces fluid in
the body
thereby
improve the
breathing of the
patient.