Assessment

Diagnosis

SUBJECTIVE:
Impaired gas
Marigatannakngaaganges exchange
as verbalize by the patient. related to
disease process.
OBJECTIVE:
Use
of
accessory
muscles
when
breathing.
Use
of
purse
lip
breathing.
Restlessness
Vital Signs:
BP- 110/80
PR- 78
RR- 25
T- 36.4

Planning

Interventions

After 4 hours of
effective nursing
intervention
patients
condition will
improve as
evidenced by
decrease
respiratory rate
from 25bpm to
20bpm.

Independent:
Monitor vital
signs.
Encourage
frequent deep
breathing
exercises.
Elevate the
head part of
the bed.
Reinforce
need for
adequate rest.
Dependent:
Administer O2
inahalation.

Rationale

To serve as a
baseline data.
Promotes
optimal chest
expansion.

To maintain
airway.

To promote
wellness.

To improve
beathing.

Evaluation
Goal met.
After 4 hours of
effective nursing
patients
condition
improved as
evidence by
decreased
respiratory rate
from 25 bpm to
20 bpm.