ASSESSMENT DIAGNOSIS SCIENTIFIC

RATIONALE
OBJECTIVES
OF CARE
INTERVENTION RATIONALE EVALUATION
Difficulty of
Breathi! "ra#i$
a$ %hallo&'
Subjective:
Nahihirapan ako sa
paghinga. as
verbalized by the
client.
Objective:
- Nasal Flaring
-slight cyanotic
nailbeds
-rapid shallo
breathing
-!!: "#cp$
%ne&&ective
breathing
pattern related
to post surgical
state as
$ani&ested by
nasal &laring'
pale skin' slight
cyanotic
nailbeds' rapid
shallo
breathing' !! o&
"# cp$
(ost Surgical
State )*aginal
+ysterecto$y
ith ,nterior and
(osterior !epair-
%nduction o&
anesthesia
).pidural-
/epression o&
$edulla
oblongata
/ecreased rate o&
respiration
/ecreased
o0ygenation to
the tissues o& the
body
1ody
co$pensates to
the decreased
o0ygen
,&ter 23
$inutes o&
nursing
intervention'
the client ill
e0perience
lessened
di&&iculty o&
breathing as
$ani&ested by
decreased in
!! &ro$ "#
cp$ to "3cp$
ith the
absence o&
nasal &laring'
and presence o&
cal$ breathing.
Independent:
- .levated head
o&
the bed &or
about 23
degrees and ask
the client to
assu$e dorsal
recu$bent
position.
- .ncouraged
deep breathing
e0ercises
- 4ept
environ$ental
pollution to a
$ini$u$
- 5onitored
respiratory
patterns'
including rate'
depth'
and e&&ort.
-.levation o& the
bed &acilitates
respiratory
&unction by use
o& gravity. %t also
decreases
pressure on the
abdo$en hen
assu$ing the
position.
- (ro$ote chest
e0pansion
-(recipitators o&
allergic type o&
respiratory
reactions that
can trigger or
e0acerbate
onset o& acute
episode.
- ,ssesses the
condition o& the
client
,&ter 23 $inutes
o& nursing
intervention'
the client
$ani&ested
lessened
di&&iculty o&
breathing as
$ani&ested by
decreased in
!! &ro$ "# cp$
to "3cp$ ith
the absence o&
nasal &laring'
and presence o&
cal$ breathing.
6oal $et.
1ody increases
pulse rate and
respiratory rate
Difficulty of
(reathi! "ra#i$
a$ %hallo&'
Dependent:
-6ave
supple$ental
o0ygen as
ordered )"7(5
via nasal
cannula-
Collaborative:
- Obtained blood
speci$en &or
,rterial 1lood
6as study
- helps in giving
ade8uate
o0ygen to the
client
- assess the
condition o& the
client