CUES NURRSING SCIENTIFIC GOALS NURSING RATIONALE EVALUATION

DIAGNOSIS RATIONALE INTERVENTIONS

SUBJECTIVE Impaired Gas Cancer is a class SHORT TERM 1. Assess >Rapid shallow Goals partially
CUES: Exchange of disease GOALS: respirations, quality, breathing and met: nagiging
Nagtikang na characterized by rate, pattern, depth, hypoventilation okay hiya pero
hiya pag kuri out of control *Patient will and breathing affect gas makadaliay la, tas
[pag hinga kun cell growth, and maintain effort. exchange by nabalik liwat
nahigda, baga lung cancer normal affecting CO2 ngahaw iton
daw hiya hin occurs when this arterial blood levels. Flaring of iyapag kuri pag
nalulumos, uncontrolled cell gas. the nostrils, hinga daughter
nanluluya na growth begins in *Patient will dyspnea, use of verbalized.
hiya tapos iton one or both be awake accessory
iya posisyon kay lungs, rather than and alert. muscles,
perme developing into *Patient will tachypnea and/
nalingkod pati healthy normal demonstrate or apnea are all
pag katurog lung tissue, these a normal signs of severe
daughter abnormal cells depth, rate, distress that
verbalized continue dividing and pattern require
and form lumps of immediate
OBJECTIVE or masses of respirations. intervention.
CUES: tissue called
*RR: 26 cpm tumor. Tumors 2. Asses for life >Absence of
*Use of interfere with the threatening ventilation,
accessory main function of problems asymmetric
muscle when the lungs which is (respiratory arrest) sound, dyspnea
breathing and to provide the with accessory
relieved when blood stream muscle use,
leaning forward. with oxygen to dullness on chest
*Orthopnea be carried to percussion and
*Restlessness entire body. gross chest wall
instability.
3. Asses for signs of
hypoxemia. >Tachycardia,
restlessness and
diaphoresis,
headache,
lethargy and
confusion are all
signs of
hypoxemia.

4. Assess for >Restlessness is

changes in an early sign of
orientation and hypoxia,
behavior mentation will
get worse as
hypoxia
increases due to
lack of blood
supply to the
brain.

5. Provide >Early
supplemental supplemental
oxygen via 100%. oxygen is
essential since
early mortality is
associated with
inadequate
delivery of
oxygenated
blood to the
 brain and vital
organs.

>Promotes
6. Position patient better lung
with head of bed 45 expansion and
degrees. improve gas
exchange.

7. Assist patient with >promotes

coughing and deep alveolar
breathing expansion and
techniques. prevents
alveolar
collapse.