NCP

ASSESSMENT Subjective: nahihirapan akong huminga as verbalized.
NURSING DIAGNOSIS Impaired gas exchange r/t ventilation perfusion imbalance.
Objective: RR26cpm PR88bpm DOB/ dyspnea Irritable Weak in appearan ce Tachycar dia Diaphore tic Use of accessor y muscles
SCIENTIFIC EXPLANATION Reduced myocardial contractility Increased cardiac workload Obstruction of left arterial emptying Pressure of blood into the pulmonary capillary bed increases Fluid shifts into the intraalveolar spaces Pulmonary congestion Impaired gas exchange
NURSING GOAL SHORT TERM GOAL Within 8 hours of rendering nursing interventions the patient will complh to the planned interventions as evidenced by: Demonstrate improve ventilation and adequate oxygenation. Verbalized understanding of causative factors and appropriate interventions. Cooperate in the treatment regimen.
NURSING INTERVENTION Independent: Note rate/ depth of respiration, use of accessory muscles, increased work of breathing, presence of dyspnea, and cyanosis.
RATIONALE
EVALUATION SHORT TERM GOAL After rendering 2-3 hors of nursing intervention goal was met aeb: Demonstration on how to improve ventilation and adequate oxygenation . -elevating head of bed -coughing and deep breathing technique -turning of position atleast every 2 hours Verbalized underst of causative factors and appropriate interventions anding Cooperation in the treatment regimen
It suggest need need for increased surveillance/ medical intervention
Assess change in Level of consciousness .
LONG TERM GOAL Throughout hospitalization the patient will -relieve from DOB/ dyspnea
Elevate head of bed. Have client turn , cough, deep breathing technique Allow adequate to rest periods between care activities. Collaborative: Provide humidified supplemental oxygen.
Hypoxemia can result in changes ranging anxiety and confusion to unresponsiveness. Promotes optimal pulmonary functionand reduces incidence of aspiration. Reduces oxygen consumption.
LONG TERM GOAL Throughout hospitalization goal was met aeb: - patient was relieved from DOB/ dyspnea.
Maintains effective ventilation/ oxygenation to prevent/ or correct respiratory crisis.
ASSESSMENT Subjective: nanghihina yung buong katawan ko as verbalized by the patient.
NURSING DIAGNOSIS Activity in tolerance r/t imbalance between oxygen supply and demand secondary to MI.
Objectives: Generalized weakness Fatigue PR-88bpm Increased BP Tachycardia Pale in appearance With minimal assistance in performing ADLs
SCIENTIFIC EXPLANATION Deficient oxygen in the coronary arteries Use of anaerobic pathway to for ATP production Decreased oxygen supply to the myocardium Inadequate amounts of oxygen to the tissues
NURSING GOAL SHORT TERM GOAL Within 8 hours of rendering nursing intervention the patient will comply/ adhere to the planned interventions as evidenced by: Use identified techniques to enhance activity intolerance. Participate willingly in the desired activities. Report measurable increase in activity tolerance Demonstrate a decrease in physiological signs of intolerance. LONG TERM GOAL Throughout the hospitalization period the patient will: tolerate ADLs
NURSING INTERVENTION Independent -Assess clints ability to perform ADLs noting reports of weakness, fatigue, and difficulty accomplishing task. -Monitor BP, PR,RR before and after activity.
RATIONALE
EVALUATION SHORT TERM GOAL Within 8 hours of rendering nursing intervention goal was met as evidenced by: Use identified techniques to enhance activity intolerance -conserving energy (sitting while performing task) -alterating rest periods Participation in the desired activities Repoted measureable increased in activity tolerance Demonstrated a decrease in physiological signs of intolerance -BP-130/80mmHg -PR- 88bpm
-Influences choice of interventions/ needed assistance
-Elevate head of bed as tolerated. -Suggest to change position slowly, monitor for dizziness. -Encourage rest periods between care activities.
-Cardiopulmo-nary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues -Enhances lung expansion to maximize oxygenation for cellular uptake -Postural hypotension/ cerebral hypoxia may cause dizziness, fainting, and increased risk of injury -Promotes rest and maintains energy level and alleviates strain on the cardiac and resp. systems. -encourages client to do as much as possible while conservimg limited energy and preventing fatigue.
-Provide assistance during activities, allowing to do as much as possible -Identify energysaving techniques (eg. sitting to perform tasks.)

NCP

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ASSESSMENT Subjective: nahihirapan akong huminga as verbalized.

NURSING DIAGNOSIS Impaired gas exchange r/t ventilation perfusion imbalance.

It suggest need need for increased surveillance/ medical intervention

Assess change in Level of consciousness .

Maintains effective ventilation/ oxygenation to prevent/ or correct respiratory crisis.

ASSESSMENT Subjective: nanghihina yung buong katawan ko as verbalized by the patient.

-Influences choice of interventions/ needed assistance

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