ASSESSMENT NURSING INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

DIAGNOSIS
Subjective: Ineffective Allergens 4/18/22 @ 9:00 Independent: 4/18/22 @ 1:00
“ Nurse breathing am 1. Assess the patient’s 1. Focused assessment pm
nahihirapan pattern Airway 7-3 shift vital signs, paying helps determine the 7-3 shift
akong huminga” related to inflammation particular attention to source of airway
as verbalized by bronchial After 4 hours of the respiratory rate, patency problems, its After 4 hours of
the patient. spasm as Swelling and nursing depth and rhythm. severity, and how it nursing
evidenced by spasm of the intervention, the affects the patient’s intervention, the
Objective: shortness of bronchial tubes patient will be breathing. patient was able to
 Audible breath and able to maintain maintain an
wheezing Narrow breathing an effective 2. Monitor the patient’s 2. To determine the effective breathing
wheezing
 Acute passages breathing pattern oxygen saturation status oxygen saturation of the pattern as
shortness of as evidenced by patient evidenced by:
Shortness of
breath normal range of 3. Teach deep breathing
breath, wheezing RR: 22 cpm
 Decreased RR, HR and and coughing exercises
3. Deep breathing and HR: 102 bpm
breath Ineffective Oxygen saturation
coughing exercises help Oxygen sat: 96%
sounds breathing pattern the patient improve
bilaterally, related to
with 4. Place the patient breathing patterns GOAL IS
bronchial spasm PARTIALLY MET.
inspiratory comfortably on a bed,or
as evidenced by 4. This position helps
and in semi-fowler position
shortness of the patient to breathe
expiratory breath and effectively by promoting
wheezes as wheezing optimum lung
auscultated 5. Encourage adequate expansion
 Presence of rest period
small Dependent: 5. To limit fatigue
amounts of 6. Administer
thin, clear https://
supplemental oxygen, as
 sputum sphweb.bumc.bu.e ordered 6. To increase oxygen
VS taken as du/otlt/MPH- saturation of patient
follows: Modules/PH/
 HR: 110 bpm RespiratoryHealth
 RR: 40 cpm /
 BP: 140/100 RespiratoryHealth
mmHg 6.html
 Sp02: 93%

Lab results:
PaC02: 27