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Assessment Subjective: Nahihirapan ako huminga as verbalized by the patient.

Objective: -increased RR : 34 -shortness of breath -facial grimace -altered body position -pale looking

Diagnosis Ineffective breathing pattern r/t hypoventilation as manifested by increased RR, shortness of breath, facial grimace, altered body position

Planning After 1hr. of Nsg. Intervention, the client will be able to verbalize awareness of causative factors.

Intervention Auscultate chest, noting presence/ character of breath sounds, presence of secretion

Rationale to identify etiology/ parcipitating factors

Evaluation After 1hr. of Nsg. Intervention, the client able to verbalized awareness of causative factors.

note rate and depth of respiration, type of breathing pattern. Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress or cyanosis encourage position of comfort

to identify etiology/ parcipitating factors

to provide for relief of causative factors

to provide for relief of causative factors

Subjective: lumalaki ang tyan ko as verbalized by the patient. Objective: -pallor -jaundice -weak in appearance -Abdominal distention noted -irritability noted -Edema -DOB with RR of 34 bpm -abdominal girth of 42

Planning Fluid volume excess After 6hrs. of r/t to compromised nursing regulatory interventions. mechanism Patient will secondary to cirrhosis demonstrate of the liver as stabilized fluid manifested by pallor, volume and jaundice, weak in decrease edema appearance, abdominal distention, and abdominal girth. irritability, Edema,
DOB with RR of 34 and abdominal girth of 42


Intervention -Monitor vital signs

Rationale -established baseline data. -Reflects circulating

volume status, developing fluid shifts, and in response to therapy

-Measure intake and output

-Monitor BP

-BP elevations are

usually associated with fluid volume excess. -Indicative of pulmonary congestion/edema -Reflects

Evaluation After 6hrs. of nursing interventions. The patient demonstrated stabilized fluid volume and decreased edema and abdominal girth.

-Assess respiratory status.

-Monitor abdominal accumulation girth. of fluid.

-Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to prevent dilutional hyponatremia

-Restrict sodium and fluids as ordered.

-Administered medication as indicated: -Diuretics

Used with caution to control edema and ascites, block effect of aldosterone, andincrease water excretion while sparing potassium.