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    Assessment Diagnosis Planning Intervention Evaluation

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    Charissa Magistrado De Leon
    The patient was experiencing shortness of breath and difficulty breathing. On examination, the patient showed signs of restlessness, cyanosis, and changes in mental status. Their oxygen levels were low. The nurse's interventions included monitoring the patient's breathing, clearing their airway, repositioning for comfort, encouraging deep breathing exercises, giving supplemental oxygen, and checking blood gases and oxygen levels. After 8 hours, the patient's breathing and oxygenation had improved.

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    Assessment Diagnosis Planning Intervention Evaluation

    Uploaded by

    Charissa Magistrado De Leon
    435 views2 pages
    The patient was experiencing shortness of breath and difficulty breathing. On examination, the patient showed signs of restlessness, cyanosis, and changes in mental status. Their oxygen levels were low. The nurse's interventions included monitoring the patient's breathing, clearing their airway, repositioning for comfort, encouraging deep breathing exercises, giving supplemental oxygen, and checking blood gases and oxygen levels. After 8 hours, the patient's breathing and oxygenation had improved.

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    Original Title

    NCP impaired gas exchange

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    The patient was experiencing shortness of breath and difficulty breathing. On examination, the patient showed signs of restlessness, cyanosis, and changes in mental status. Their oxygen levels were low. The nurse's interventions included monitoring the patient's breathing, clearing their airway, repositioning for comfort, encouraging deep breathing exercises, giving supplemental oxygen, and checking blood gases and oxygen levels. After 8 hours, the patient's breathing and oxygenation had improved.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    435 views2 pages

    Assessment Diagnosis Planning Intervention Evaluation

    Uploaded by

    Charissa Magistrado De Leon
    The patient was experiencing shortness of breath and difficulty breathing. On examination, the patient showed signs of restlessness, cyanosis, and changes in mental status. Their oxygen levels were low. The nurse's interventions included monitoring the patient's breathing, clearing their airway, repositioning for comfort, encouraging deep breathing exercises, giving supplemental oxygen, and checking blood gases and oxygen levels. After 8 hours, the patient's breathing and oxygenation had improved.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    Assessment Diagnosis Planning Intervention Evaluation

    SUBJECTIVE: Impaired gas


    exchange related  Noted
    “Nakakaranas ako to altered oxygen Long term: respiratory Long term:
    ng hingal sa supply. After 8 hours of rate, depth, After 8 hours of
    paghinga” nursing and ease of nursing
    intervention the respirations. intervention the
    patient will Observef for patient was able
    OBJECTIVE: demonstrate the use of to
    improved accessory demonstrate
     Restlessne ventilation and muscles, improved
    ss adequate pursed lip ventilation and
     Cyanosis oxygenation of breathing, adequate
     Changes tissues by ABGs changes in oxygenation of
    in within patient’s skin or tissues by ABGs
    mentation normal range. mucous within patient’s
    membrane normal range.
    T: 37.1 ˚C color.
    P: 101
    R: 32  Auscultated
    BP: 120/ 8 lungs for air
    O²: 65mmHg movement and
    abnormal
    breath sounds.

     Investigated
    restlessness
    and changes
    in mentation or
    level of
    consciousness

     Maintained
    patent airway
    by positioning,
    suctioning,
    use of airway
    adjuncts.

     Repositioned
    frequently,
    placing patient
    in sitting
    positions and
    supine to side
    positions.

     Avoided
    positioning
    patient with a
    pneumonecto
    my on the
    operative side.
    Favor the
    “good lung
    down”
    position.

     Encouraged or
    assist with
    deep
    breathing
    exercises and
    pursed-lip
    breathing as
    appropriate.

     Administered
    supplemental
    oxygen via
    nasal cannula,
    partial
    rebreathing
    mask, or high
    humidity face
    mask as
    indicated.
     Monitored
    graph of
    ABGs, pulse
    oximetry
    readings.

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