Beruflich Dokumente
Kultur Dokumente
PLANNING GOALS OF INTERVENTION CARE RATIONALE >At the end of nursing interventions, patient will be able to: 1. Report feeling comfortab le when breathing. 2. Report feeling rested each visit. W/ IMPLEMENTATION EVALUATION
S: Hindi siya mkahinga ng normal.as the mother verbalized. O: >Restlessness >weaklooking >Crackles sound >Shallow breathing >RR=50 breath/min
1. Assess and record RR and depth at least every hour. R : To detect early signs of respiratory compromise. 2. Assist patient to comfortable position, such as supporting upper extremities with pillows. R : These measures promote comfort and chest expansion. 3. Schedule necessary activities to provide periods of rest.
3. When patient carries out activities of daily living, breathing pattern remains normal, RR is 20 breath/min.
R : Prevents fatigue and reduces Oxygen demands. 4. Note emotional responses; crying and grasping. R : Hyperventilation may be a factor. 4. Observed emotional responses like crying and grasping. 4. Patient showed appropriate behaviour and cooperative.