ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION
SUBJECTIVE: Impaired gas exchange After 8 hours Independent: Goal – met
r/t of nursing when patient
ventilation perfusion intervention the 1. Elevated head of 1. To maintain airway was able to demonstrate
imbalance. patient will be able bed/ position client improved ventilation and
to: appropriately, provide adequate oxygenation of tissues
OBJECTIVE: airway adjuncts and suction as by HBGs within clients normal limits.
indicated.
Patient is restless. 1.Demonstrate 2. Promotes optimal
Rate ,rhythm and improved 2.Encouraged frequent deep chest expansion and
depth of breathing Ventilation and breathing/ coughing exercises. drainage of secretions.
is abnormal. adequate
Nasal flaring was oxygenation of 3. Reveals presence of
noted tissues by HBGs 3. auscultated breath sounds pulmonary congestion/
within clients noting crackles, wheezes collection of secretion,
normal limits indicating need for further
intervention.
2.Participate in
treatment regimen
(e.g, breathing
exercises ,effective
coughing, use of Collaborative:
oxygen) within level 1. To improve
of ability/situation. 1. Assisted with procedures respiratory
as individually indicated function/oxygen-carrying
(e.g., transfusion, capacity
3.Verbalize phlebotomy, bronchoscopy)
understanding of
causative factors
and appropriate
intervention.

\ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

 INTERVENTION
Acute Pain Short term: >establish rapport. > to gain pt’s. trust. Short term:
After 4º of NI, the
pt’s. rate of pain >to note for additional After 4º of Nursing Intervention the pt’s.
will decrease >asses pt’s. abnormalities and for rate of pain
from6/10 to generalcondition. further evaluation decreased
3/10.Long term: of it. from 6/10 to 3/10.

>monitor and record Long term:

Long term: VS. > to obtain baseline
After 3 days of NI, the data for comparison. After 3 days of NI, the pt. demonstrated
pt. will demonstrate >auscultate breath nonpharmacologic methods
nonpharmacologic sounds. >to note for other that provide relief of pain.
methods that respiratory symptoms
provide relief of such as rales/crackles,
pain. >provide safety wheezes, etc. and for
measures promotion
of relaxation and may
enhance coping
abilities by refocusing
attention.