"Nanghihina Ako Tsaka Wala Akong Ganang Kumain" As Verbalized
"Nanghihina Ako Tsaka Wala Akong Ganang Kumain" As Verbalized
"Nanghihina Ako Tsaka Wala Akong Ganang Kumain" As Verbalized
Collaborative:
Monitoring of lab results
Proper nutrition to meet the increasing
metabolic needs
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS & RATIONALE EVALUATION
Subj: Impaired gas exchange Goal: Independent: Criteria:
Dahan-dahan lang ako r/t alveolar-capillary At the end of 6 hrs, the Assess respiratory & mental At the end of 6 hrs,
gumalaw kasi madali akong membrane changes due patient will be able to status & level of energy of the the patient is now
mapagod at nahihiran akong to pleural effusion & participate in treatment client to monitor any able to participate in
huminga. Nahihilo rin ako. as regimen (DBE & use of respiratory changes treatment regimen
pulmonary mass
verbalized oxygen) within the level of Monitor VS (cardiac (DBE & use of
ability/situation rhythm) to note signs of oxygen) within the
oxygenation changes level of
Obj:
Applied aseptic techniques ability/situation
Patient manifests confusion,
(washing of hands, wearing of
restless & irritability
masks)decrease the risk of
infection
Clubbing of fingers & toes
Encourage to elevate head of
bed & position properly to
Has pale & dry skin
facilitate respiration
Maintain adequate input &
RR is 38 bpm
output to avoid fluid
overload
PR is 113 bpm
Encourage to do DBE to
increase comfort & maximize
BP is 120/80 mmHg
the areas of the lungs for
proper lung expansion &
O2 sat is 92%
perfusion
Encourage adequate rest &
Decreased breath sounds on left
limit activities within clients
side lung upon auscultation
tolerance & promote calming
environment reduce oxygen
Has nasal flaring
needs & consumption
Health teaching on maintaining
Increased breathing depth
a good hygiene (wound
dressing/basic hygiene) for
Dull upon percussion on left side
them to be informed that it
lung
helps to reduce the risk of
infection
Abn ABGs (hypoxia,
hypercapnia)
Dependent:
Provide oxygen as ordered
Collaborative:
Collaborate to medtech for monitoring
of CBC & pulmonary studies