Jasmin, Niña Grace S.

BSN 3B
General Nursing Unit - GGH Clinical Instructor: Prof. Melanie Francisco

Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Impaired gas After 8 hours of ● Assess and Decreased oxygen After 8 hours of
“Hirap pa rin ako exchange related nursing check the levels hinder the nursing
huminga” as stated by to altered intervention, the patient’s absorption of intervention, the
the patient. oxygen-carrying client will manifest hemoglobin oxygen at the lung's client manifests
capacity of blood absence of levels. air sacs and its absence of
Objective data: secondary to symptoms of transport to body symptoms of
● Tachypnea anemia as respiratory distress. tissues. respiratory distress.
● CBC Results of: evidenced by
○ HGB - 82 body malaise and ● Support the Correct positioning
○ HCT - 0.23 tachypnea client with helps prevent
○ RBC - 269 pillows or muscle fatigue and
● Malaise cushions as reduces the strain
● Use of needed for on breathing,
accessory comfort and enabling the
muscles proper individual to
alignment. breathe more
Vital Signs effectively and
● BP - 120/70 improving oxygen
● PR - 89 levels.
● RR - 24
● O2 - 95 ● Maintain an Additional oxygen
oxygen might be necessary
administrati to keep arterial
on device as oxygen levels
ordered, (PaO2) within an
 attempting acceptable range.
to maintain
oxygen
saturation at
90% or
greater.

● Administer Administering
humidified oxygen with
oxygen distilled water as a
through an humidifier prevents
appropriate the drying of the
device. mucosa.

● Schedule The nurse should

nursing care assist the patient
to provide with activities to
rest and conserve energy
minimize reserves due to
fatigue. restricted oxygen
availability.