ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective : Ineffective breathing pattern After 10-15 minutes of - Administer oxygen at - For management of Goal met.
r/t alteration of client’s appropriate nursing lowest concentration underlying
“Nahihirapan akong huminga” normal 02:CO2, mucus, intervention the patient will indicated and pulmonary condition, The patient able to
as verbalized by the patient. bonchoconstriction, and be able to establish a normal, prescribed respiratory respiratory distress or established a normal
airway irritants as manifested effective respiratory pattern medications. cyanosis effective pattern and
Objective : by vital signs: as evidenced by absence of - Elevate head of bed - To promote verbalize awareness of
RR : 28 cyanosis and other and or have client sit physiological use of causative factors.
- Difficulty of breathing
- Vital Signs PR : 97 signs/symptoms of hypoxia up in chair as maximal inspiration
RR : 28 Temp. : 37⁰C with ABCs within client’s appropriate.
PR : 97 BP : 130/80 normal on acceptable range. - Encourage slower - To assist client in
Temp. : 37⁰C and difficulty of breathing. and deeper taking control of the
BP : 130/80 respirations, use of situation
pursed-lip technique
- Monitor pulse - To verify
oximetry maintenance/
improvement in O2
- Suction airway as - To clean secretions
needed
- Auscultate chest - To evaluate
presence/ character
of breathe sounds
and secretions
- Encourage adequate - To limit fatigue
rest periods between
activities
 ASSESSMENT
Subjective :
“Madanagan nak ti salung-at
ku” as verbalized by the
patient.
Objective :
- Poor eye contact
- Increase wariness
DIAGNOSIS
Anxiety r/t situational/
nutritional rises as manifested
by poor eye contact, increase
wariness.
PLANNING
After 8-10 hours of
appropriate Nursing
Intervention the patient will
be able to appear relaxed and
report anxiety is reduced to a
manageable level, and
verbalize awareness of
feelings of anxiety.
INTERVENTION RATIONALE EVALUATION
- Promote accurate - Helps client identify Goal met
information about the what is reality base
situation The patient able to appear
- Establish a - To avoid the relaxed and report anxiety is
therapeutic contagious effect for reduced to a manageable
relationship, transmission of level, and verbalize
conveying empathy anxiety awareness of feeling of
and unconditional anxiety.
positive regard
- Encourage client to - Which may some to
develop an reduce level of
exercise/activity anxiety by relieving
program tension
- Refers to individual - To deal with chronic
and/or group therapy anxiety states
as appropriate
- Review strategies, - Useful for being
such as role playing, prepared for dealing
use of visualizations with anxiety-
to practice anticipated provoking situations
events, prayer
meditations
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective : Acute pain r/t to over time After 30-45 minutes of Dependent Goal met.
ongoing injury and prepare appropriate Nursing
“Masakit dibdib ku” as process causes scar tissue Intervention the patient will - Administer o2 at - For management of The patient able to follow
verbalized by the patient. formation and narrowing of be able to follow prescribed lowest concentration underlying prescribed pharmacological
the airway lumen as pharmacological regimen and indicated prescribed pulmonary condition, regimen and report pain is
Objective : manifested by report pain is relieve or respiratory respiratory distress, relieved or controlled.
- (+) grimace controlled. medication with or cyanosis and chest
- (+) grimace analgesics pain
- Pain scale of 7/10 - Pain scale of 7/10
- Vital Signs: - Vital Signs:
RR : 28 Independent
RR : 28
PR : 97 PR : 97 - Assist patient to learn - To assist in muscle
Temp. : 37⁰C Temp. : 37⁰C breathing techniques and generalized
BP : 130/80 BP : 130/80 relaxations
- Be alert to changes in - May indicate new
pain physical problem
- Evaluate pain - May be exaggerated
behaviour because client’s
perception of pain is
not relieved or
because clients
believes that
caregivers are
discounting reports
of pain
- Encourage right-brain - To release
stimulation with endorphins,
activities such as enhancing sense of
well being
- Include client and - To limit focusing on
SO(s) in establishing pain
pattern of discussing
pain for specified
length of time
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective : Disturbed sleep pattern related After 4-7 hours of - Assess client’s usual - To ascertain intensity Goal met.
to unfamiliar sleep appropriate Nursing sleep patterns and and duration of
“ Hindi ako masyadong surrounding, interruptions Intervention the patient will compare with current problems The patient able to identify
makatulog” as verbalized by (e.g. for therapeutic be able to identify sleep pattern individually appropriate
the patient. monitoring, lab test) as individually appropriate disturbance, relaying intervention to promote sleep
manifested by change in interventions to promote on client or SO report and report improved sleep.
Objective : normal sleep pattern. sleep and report improved of problem
- Change in normal sleep. - Request visitors to - Sign as indicated to
sleep pattern leave, close room provide privacy
door
- Incorporate screening - To evaluate the type
information into in and etiology of sleep
depth sleep diary or disturbance and to
testing if needed identify useful
treatment options
- Perform monitory - Allows for longer
and care activities periods of
without waking client uninterrupted sleep,
whenever possible especially during
- Provide bedtime care night
- To promote physical
comfort