Assessment

Problem: Difficulty
breathing

Nursing Diagnosis

Impaired gas
exchange related to
alveolar capillary
membrane changes
as evidenced by
Subjective:
difficulty of
Nahihirapan po
akong huminga., as breathing,
respiratory rate of
verbalized by the
38 cycles per
client.
minute, pulse rate of
102 beats per
minute, positive
Objectives:
crackles at right
RR: 38
lower thorax, harsh
cycles/minute
breath sounds at the
right chest area, use
PR:102
of accessory
beats/minute
muscles and pale in
with positive
appearance.
wheezes at right
lower thorax.
use of accessory
muscles in
breathing
pale in appearance

Planning

Intervention

Rationale

Goal:

Independent:

After 8 hours of
intervention, the client
will be able to
demonstrate improved
ventilation and
oxygenation of tissues
within clients normal
limits.

1. Evaluate the clients

vital capacity

1. To assess respiratory
insufficiency

2. Assist the client in a

semi-fowlers position

2. Facilitate easier
breathing

3. Emphasize adequate
rest

3. Promotes comfort

Outcomes:
After the interventions,
the client will be able to
show:
clear breath sounds
eliminate dyspnea
prevent the used of
accessory muscles
respiratory rate of <25
cycles per minute
relaxation to condition

Evaluation
The goal was met.
After 8 hours of
intervention, the
client was able to
show adequate gas
exchange such as:
clear breath sounds

4.Encourage adequate
oral fluid intake of 2000
ml per day

4. Helps liquefy
secretions

no dyspneic
episodes

5.Have standby oxygen

5.For emergency use

free breathing
without use of
accessory muscles

Dependent:
6. Administer
mucolytics as
prescribed.
7. Administer
antibiotics, as ordered
and monitor for side
effects
8. Administer
bronchodilator as
recommended.

6. Decreases mnusus
viscosity

7. Avoids further
multiplication of
microorganisms.
8. Helps enhance
passage of air to the
airway

respiratory rate of
19 cycles per
minute.
relaxed and lighten
face