ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective Impaired gas After 1 hour of >Monitor RR,depth and effort “Goals met”
“Nahihirapan exchange related nursing including of accessory muscles The client is improved ventilation from
huminga ang anak to ventilation intervention the ,nasal flaring and abnormal
ko” perfusion client will breathing patterns P-145
imbalance improve
Objective ventilation >Auscultate every breath RR-22
-Restlessness sounds every 1-2 hours
-Irritability
-Tachycardia- >Monitor the clients behavior
P 181 for the onset of restlessness
-Cyanosis
-Diaphoresis >Observe for cyanosis of the
-Nasal Flaring skin especially note the color,
-Tachypnea RR-41 tongue and oral mucus
-Barrel chest membrane
-Wheezing on
expiration >Position the client in Semi
fowlers with an upright
position at 45 degree if
possible
>Administer bronchodilator as
ordered by the doctor