NAME: LESMORAS, JUDY ICELEY H. BSN 3-B CI: CHESCA MAE C.

ELCEDULAN DATE: 03 -10 - 24

Cues/ Evidences Nursing Diagnosis Outcome Criteria Nursing Intervention Rationale Evaluation

Subjective: Ineffective After 4 hours of • Position semi – • Assist patient to find a comfortable Patient was able
 “sakit ang breathing pattern nursing upright position that promotes lung expansion: demonstrate
tinahian” r/t post operative interventions, the such as sitting upright or semi-fowler's improved breathing
with a pain pain as evidenced patient will position. pattern as evidenced
scale rating by decreased demonstrate • Educate on pursed • Teach and encourage deep breathing by:
7/10 as oxygen saturation improved breathing lip and deep exercises to improve lung expansion and
verbalized levels, difficulty pattern as evidenced breathing exercises ventilation.
breathing and by: • Return
Objective: cough • Encourage • Encourage early mobilization and demonstrated
• Oxygen ambulation for 15- ambulation as tolerated to promote lung pursed lip
BP: 140/ 80 mmHg saturation 30 mins every expansion and prevent complications and splinting
Temp: 37.1 c levels within 3 hours or as such as atelectasis. of rib cage
O2sat: 95% normal range tolerated during deep
PR: 95 bpm (O2sat ≥ breathing
RR: 25 cpm 95%). • Instruct to splint rib • Splinting the rib cage with a pillow exercises or
 Labored cage using pillow provides support and reduces pain when
breathing • Absence of during deep during these activities. coughing.
 Cough difficulty breathing exercises
breathing. or when coughing • Improved
• Help divert the patient's focus away lung
• Improved • Provide distraction from pain and discomfort. expansion.
lung techniques: guided
expansion. imagery and deep • Reduced
breathing exercises cough
• Reduced • Administer analgesics as prescribed to frequency.
cough • Administer alleviate post-operative pain. Encourage
frequency. prescribed patient to report pain promptly for timely
medications intervention.