PHINMA University of Pangasinan

College of Health Sciences

Patient’s Initials: JDC Age & Gender: 77 y/o Male
Birthday: September 8, 1946
Address: Dagupan City, Pangasinan
Chief Complaint: Dyspnea, Fatigue, and Nausea
Admitting Diagnosis: Impaired Gas Exchange
Date of Confinement: March 21, 2023
Name of Student Nurse: Christian A. Joves
Level/block/group: BSN1-15
Hospital/area: Region 1 Medical Center
Clinical Instructor: Alliah Grace N. Garcia Date: March 22,
2023

ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired gas exchange Following an 8-hour shift, the INDEPENDENT Following an 8-hour shift, the
indicates excess or deficit in patient will be able to: • Assess for pain or • To deliver patient can:
“Patient says he oxygen saturation or carbon appropriate
discomfort that
experienced shortness dioxide elimination at the care for the
may restrict
of breath, fatigue, and Short Term Goals patient Short Term Goals
alveolar-capillary membrane., respiratory effort.
nausea.” giving the impression that not • To carry out
• Verbalize effective • Verbalize effective
enough air is being able to enter • Check vital signs appropriate
Objective: respiratory patterns. respiratory patterns.
the lungs. interventions
• Demonstrate every 4 hours or as
if vital signs • Demonstrate improved
Diaphoretic, needed.
improved ventilation ventilation and adequate
Weak cough, deviate.
and adequate
Fast, Shallow Breath, • Auscultate breath • To detect oxygenation of tissues.
oxygenation of tissues.
Crackles sound in the decreased or • Demonstrate appropriate
• Demonstrate sounds at least
adventitious
Lungs every 4 hours. coping behavior and
appropriate coping breath sounds
BP: 110/70 mmHg methods to improve
behavior and methods
PR: 114 bpm • Put the patient in a • To permit breathing patterns.
to improve breathing
RR: 28 bpm position that maximum • Achieved vital signs
patterns.
Temp: 38.5 0C lung excursion
• Achieve vital signs maximizes his normal range.
O2Sat: 90 0/0 breathing rhythm. and chest
normal range.
expansion.
• Suction airway, as • To clear the
NURSING DIAGNOSIS Long Term Goal
Long Term Goal needed obstruction
Impaired gas exchange from the • The patient use a method
related to shortness of • The patient will have airway.
the ability to use a • Assist the patient that enhances his
breath as evidenced by with ADLs, as • To avoid breathing pattern and be
increased respiratory method that will overexertion
enhance his breathing needed
and fatigue.
 rate, pulse rate, and EXPLANATION OF THE PROBLEM pattern and be free DEPENDENT free from signs
low oxygen saturation. from signs • To prevent and symptoms.
A person who is having and symptoms. • Give medicines and and control
impaired gas exchange feeling oxygen, per
• The patient will initiate symptoms. • The patient initiated
short of breath, having trouble doctor’s orders.
lifestyle changes and lifestyle changes and do
inhaling or exhaling and
do measures to measures to breathe
sometimes it is associated with a
breathe effectively. COLLABORATION effectively.
weak cough and shallow
• To facilitate
breathing that can arise to other • Refer to a specific GOAL MET
independence
conditions. supplier for
supplemental
oxygen or
necessary
respiratory
devices.