Nursing

Diagnosis
Impaired Gas
Exchange secondary
to ventilation and
perfusion inequality;
Related to retained
secretions as
Evidence by
Tachycardia,
Tachypnea, crackles,
wheezing and
cyanosis.

Objectives
Short Term:

Nursing Diagnosis

Rationale

Evaluation

Independent:
Short Term:

Within 15 mins of
duty, Difficulty of
breathing will be
lessened.
Long Term:
After 1 day of
Nursing
Intervention pt.
Will demonstrate
improvement in
ventilation and
adequate
oxygenation within
Normal limits and
having absence
symptoms of
respiratory Distress

Elevate the head of the

bed 45 degrees or Semi
fowlers position.

It maximized lung
expansion thus sustain
open Airway

Advised patient to keep

calm During the
episodes of breathing
difficulty

To prevent aggravating
of the disease.

Encouraged deep
controlled breathing
exercise.

It promotes optimal
chest expansion.

Dependent:
Low Flow O2 inhalation
via Nasal Cannula as
ordered by Physician.

Administer Nebulizer as
Ordered by Physician

Administer AntiInflammatory agents as

ordered.

To Promote the O2
need of the patient.
(Giving of High Flow O2
may remove the
Hypoxic Drive- leading
to Increased
Hypoventilation,
Respiratory
Decompression and
worsening the
Respiratory Acidosis.
It Smoothen Smooth
Muscles cells of the
respiratory tract
causing smooth muscle
relaxation.

Patient Verbalized
Medyo naka ginhawa na
ako
Goal Partially Met.
Long Term:
Patient demonstrate
improvement in
ventilation and
adequate oxygenation
within Normal Limits
and absence symptoms
of respiratory Distress.
Decreased use of
Accessory Muscles
when Breathing,
absence of Nasal
Flaring, and Decreased
Respiratory Rate.

These are used to

suppressed airway
inflammation and
reduce asthma
symptoms. It blocks
late response to inhaled
allergens and reduce
Bronchial Hyper
responsiveness.