ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective Data: Nahihirapan akong huminga verbalize by the patient. Objective Data: - Received patient lying on bed. - Weak in appearance - Use accessory muscles in breathing. - Pale - VS taken and recorded Temp= 36.1 RR= 24 bpm CR= 112 bpm BP= 110/60 mmhg

Impaired gas exchange related to pulmonary congestion as manifested by difficulty of breathing..

After 2 hrs of nursing intervention the patient will manifest decrease respiratory effort as evidenced by absence of dyspnea.

Assess activity tolerance; encourage rest periods and limit activities to client tolerance

This parameters assist in determining client response to resume activities and ability to participate in self care.

After nursing intervention the patient manifested decreased respiratory effort as evidenced by absence of dyspnea.

Elevate the head of the bed.

Promote maximal chest expansion.

Assisted with frequency changes of position and ambulation.

Turning and ambulation enhance aeration of different lung segment, thereby improving oxygen diffusion.

Assisted client to deal with fear anxiety that may be present.

Feelings of fear and anxiety are associated to breathe and may actually increase oxygen consumption and demand.

Encourage deep breathing exercise.

Deep breathing facilitates maximum expansion of lungs and the smaller airways.