ASSESSMENT DIAGNOSIS SCIENTIFIC OBJECTIVES INTERVENTION RATIONALE EVALUATION

RATIONALE OF CARE
Difficulty of Ineffective Post Surgical Independent:
Breathing (rapid breathing State (Vaginal After 30 - Elevated head -Elevation of the
After 30 minutes
and shallow) pattern related Hysterectomy minutes of of bed facilitates
to post surgical with Anterior and nursing the bed for respiratory of nursing
Subjective: state as Posterior Repair) intervention, about 30 function by use
intervention,
“Nahihirapan ako sa manifested by the client will degrees and ask of gravity. It also
paghinga.” as nasal flaring, Induction of experience the client to decreases the client
verbalized by the pale skin, slight anesthesia lessened assume dorsal pressure on the
manifested
client. cyanotic (Epidural) difficulty of recumbent abdomen when
nailbeds, rapid breathing as position. assuming the lessened
Objective: shallow Depression of manifested by position.
difficulty of
- Nasal Flaring breathing, RR of medulla decreased in
-slight cyanotic 27 cpm oblongata RR from 27 - Encouraged - Promote chest breathing as
nailbeds cpm to 20cpm deep breathing expansion
manifested by
-rapid shallow Decreased rate of with the exercises
breathing respiration absence of - Kept -Precipitators of decreased in
-RR: 27cpm nasal flaring, environmental allergic type of
RR from 27 cpm
and presence of pollution to a respiratory
Decreased calm breathing. minimum reactions that to 20cpm with
oxygenation to can trigger or
the absence of
the tissues of the exacerbate
body onset of acute nasal flaring,
episode.
and presence of
Body - Monitored - Assesses the calm breathing.
compensates to respiratory condition of the
the decreased patterns, client
oxygen including rate, Goal met.
depth,
and effort.
Body increases
pulse rate and Dependent:
respiratory rate
-Gave - helps in giving
supplemental adequate
Difficulty of oxygen as oxygen to the
breathing (rapid ordered (2LPM client
and shallow) via nasal
cannula)

Collaborative: - assess the

- Obtained blood condition of the
specimen for client
Arterial Blood
Gas study