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Saturday, November 27, 2010

NCP- DOB (Click Here)


ASSESSMENT

DIAGNOSIS
OBJECTIVES
OF CARE
INTERVENTION
RATIONALE
EVALUATION
Difficulty of Breathing (rapid and shallow)

Subjective:
“Nahihirapan ako sa paghinga.” as
verbalized by the
client.

Objective:
- Nasal Flaring
-slight cyanotic nailbeds
-rapid shallow breathing
-RR: 27cpm
























Ineffective breathing pattern related to post surgical state as manifested by nasal flaring, pale skin, slight cyanotic nailbeds, rapid shallow breathing, RR of 27 cpm

After 30 minutes of
nursing intervention,
the client will experience lessened difficulty of breathing as manifested by decreased in RR from 27 cpm to 20cpm with the absence of nasal flaring, and presence of calm breathing.

 Independent:
- Elevated head of
the bed for about 30 degrees and ask the client to assume dorsal recumbent position.


- Encouraged deep breathing exercises
- Kept
environmental
pollution to a
minimum





- Monitored
respiratory patterns,
including rate, depth,
and effort.

Dependent:

-Gave supplemental oxygen as ordered (2LPM via nasal cannula)

Collaborative:
- Obtained blood specimen for Arterial Blood Gas study

-Elevation of the
bed facilitates
respiratory
function by use
of gravity. It also decreases pressure on the abdomen when assuming the position.

- Promote chest expansion

-Precipitators of
allergic type of
respiratory
reactions that
can trigger or
exacerbate
onset of acute
episode.

- Assesses the condition of the client




- helps in giving adequate oxygen to the client

- assess the condition of the client

After 30 minutes of  nursing intervention,
the client manifested lessened difficulty of breathing as manifested by decreased in RR from 27 cpm to 20cpm with the absence of nasal flaring, and presence of calm breathing.

Goal met.

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