Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
S>”nakakaranas Impaired Gas After 8 hrs of Independent: >After 8 hrs
daw sya ng pag Exchange r/t nursing >Note: respiratory >Respiration may be of nursing
hingal sa altered oxygen interventions the rate depth, and ease increased as a result interventions
paghinga at supply pt will of respirations. of pain or as an initial the pt was
pananakip ng demonstrate Observe for the use of compensatory able to
dibdib” As improve accessory muscle, mechanism to demonstrate
verbalized by the ventilation and pursed lips breathing, accommodate for loss improve
watcher. adequate changes in skin or of lung tissue. ventilation
oxygenation of mucous membrane and
O>Restlessness tissue by ABG’s color. adequate
>cyanosis within pt normal >Consolidation and oxygenation
T: 37 range. >Auscultate lungs for lack of air movement of tissue by
P:90 air movement and on operative sides are ABG’s within
R:25 abnormal breath normal in the pt normal
BP: 140/90 sounds. pneumonectomy pt. range.

>May indicate
>Investigate increased hypoxia or
restlessness and complications such as
changes in mentation mediastinal shift
or level of pneumonectomy pt
consciousness. when accompanied
by tachypnea,
tachycardia, and
tracheal deviation.

>Airway obstruction
>Maintain pt airway impedes ventilation,
by positioning impairing gas
suctioning, use of exchange.
airway adjuncts.
>Promotes maximal
>Encourage or assist ventilation and
with deep breathing oxygenation and
exercise and pursed reduces or prevent
lip breathing as atelectasis.
appropriate.

Dependent: >maximizes available

>Administer oxygen, especially
supplemental oxygen while ventilation is
via nasal cannula, reduced because of
partial rebreathing pain.
mask or high humidity
face mask as
indicated. >Decreasing PaO2 or
increasing PaCO2
>Monitor graph of may indicate needs
ABG’s pulse oximetry for ventilatory
reading support.
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
S>”Hinahapo siya Fatigue r/t After 8 hrs of Independent: >After 8 hrs
palagi” as decrease nursing >Monitor and assess >To evaluate fluid nursing
verbalized by the hemoglobin interventions the vital signs. status and cardio interventions
watcher. level as pt will report pulmonary response the pt was
evidence by improved sense to activity. able to
O>Weak CBC results. of energy. >Encourage report
>Pale in nutritionally dense >To promote energy improved
appearance easy to prepare foods. consumptions sense of
>with rr of 25 through foods. energy.
bpm >Encourage use of
assistive devices. >To avoid any
possible accident.
Dependent:
>Administer O2
inhalation as ordered >To improve pt’s
by the admitting oxygenation.
physician.
Assessment Nursing Planning Interventions Rationale Evaluation
Diagnosis
S>”Hindi siya Anxiety r/t After 8 hrs of Independent: >After 8 hrs
mapakali dahil perceived nursing >Encourage >To identify nursing
takot siyang threat of death interventions the verbalization of contributing factors interventions
mamatay” as pt will identify feelings. r/t anxiety. the pt was
verbalized by the and express able to
watcher. feelings freely >Encourage asking >To give information identify and
and will have questions in deviation and avoid express
O>Restlessness positive outlook to current health misconceptions. feelings and
>Irritability towards reality status. was able to
>Increase RR after a series of positive
nursing >Provide calm, fresh, >To promote outlook
interventions. and peaceful relaxation towards
environment. reality.

>Assist to engage >To reduce guilt

spiritual growth feelings and conflicts
activities and allow to move forward
forgiveness to heal towards resolution.
past hurts.
>To enchance sense
>Provide opportunities of control.
to make decisions.