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SUBJECTIV Impaired After 24hrs *INDEPENDENT: -Tachypnea indicates After 24 hrs of Goal met.
E: Gas of nursing 1. Assess respiratory respiratory distress esp thorough nsg. Seen pt. lying
exchange intervention: status, noting signs of when respi are Intervention, on bed
As r/t patient will respiratory distress >75cpm/min after the patient was without the
verbalized immature be (e.g., tachypnea, nasal first 5 hours of life. able to breathe oxyhood.
by the pt pulmonary gradually flaring, grunting, Expiratory grunting normally
SO: “naa functioning weaned to retractions, rhonchi, or represents attempt to without
na’y oxygen room air and crackles). maintain alveolar supplemental
nga breathe expansion; nasal flaring oxygen.
nakataod sa normally is a compensatory
iya.” without mechanism to increase
supplementa diameter of nares &
l oxygen. 2. Assess skin color for increase Oxygen intake.
dev’t of cyanosis.
3. Promote rest,
OBJECTIVE: -Lack of Oxygen will
minimize stimulation
-dyspnea result in cyanosis.
& energy expenditure.
noted
-RR= -to decrease the
-rapid, equal *COLLABORATIVE: metabolic rate & Oxygen
chest 1. Monitor consumption.
expansion lab/diagnostic studies
as appropriate.
*COLLABORATIVE:
1. Provide or -Helps prevent seizures
administer meds as associated with
prescribed. hyperthermia and
Assessm Nursing Nursing Nursing Rationale Outcome Actual
ent Diagnosis Goal Intervention Criteria Evaluation