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Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale Evaluation

S – “Hinahapo ako” Ineffective airway After a series of >Administered 02 -to compensate for the limited The patient exhibits
O – received patient on clearance related to interventions, inhalation as prescribed oxygen supply less difficulty in
bed asthma and excessive the patient will >Monitored - to assess if the first intervention breathing
Conscious and mucus. exhibit less respirations is working
coherent difficulty in >elevated head of bed -to facilitate maximum expansion
Ambulatory breathing. of lungs
Difficlty of breathing >encouraged deep -to encourage relaxation and
RR 30 cpm – more breathing exercises mobilize secretions
than normal range >monitored vital signs, -to assess the effectiveness of the
Coughing noting bp and pulse interventions given above and
Wide eyed changes check for other problems
Nasal flaring >due meds given as
prescribed
Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale Evaluation
S- “kulang ako sa tulog Sleep deprivation After the shift, >assisted in nebulizing -to loosen secretions The patient is able
sa hapo” related to prolonged the patient will and backtapping to sleep and rest
O – received patient discomfort secondary be able to sleep >encouraged the -to relax the patient and mobilize during the shift.
sitting in bed to coughing and and rest. patient to do deep secretions
Conscious and difficulty of breathing. breathing exercises
coherent >positioned the client -to facilitate maximum expansion
Difficulty of breathing at high back rest of the lungs
Chest indrawing >encouraged SO to -to assist the patient and minimize
Productive cough assist patient in having movements since the patient is
Restlessness a more comfortable experiencing less sleep.
sleep environment such
as environmental
control
>encouraged patient to
expectorate or cough -to lessen secretions and clear the
out sputum airway.
>due meds given as
prescribed
Assessment Nursing Diagnosis Scientific explanation Planning Intervention Rationale Evaluation
S – “hinahapo ako pag Activity intolerance After the shift, >monitor vital signs -to asses baseline data The patient
pumupunta sa CR” related to imbalance the patient will >adjust activities to -to minimize overexertion demonstrated ease
O – received patient in between O2 supply and demonstrate prevent overexertion of breathing and
bed demand as evidenced ease of >positioned the patient -to facilitate maximum expansion exhibit normal
Conscious and by exertional dyspnea. breathing and in HBR of the lungs breathing patterns.
coherent will gradually >Encouraged the SO to -to minimize overexertion of
On DAT exhibit normal assist patient in doing patient
RR – 22 cpm which is breathing ADL
above normal range patterns. >encouraged patient to -to exercise lungs and relax the
BP – 130/40 which is do deep breathing patient
above normal range exercises
DOB during exertion >encouraged patients -to prevent further complications
to minimize exposure and asthma attack
to polluted
environment
>nebulization done c/o -to mobilize secretions and clear
pulmonologist airway.
>due meds given