Assessment

Nursing Diagnosis

Planning

Intervention

Rationale

Evaluation

Subjective: Nabudlayan nag id siya mag ginhawa kag nahapo siya: as verbalized by folks.

Impaired gas exchange related to Carbon dioxide retention.

After 8 hours of nursing intervention patient or family members will state understanding of causes for impaired gas exchange and behaviors to prevent it.

Independent: Elevate head of To facilitate breathing GOAL UNMET bed/position client and lung expansion. appropriately. Encourage frequent To improve existing position changes deficiencies. Suction patient as needed. Suctioning aides to remove secretions from the airway and optimizes gas exchange. Dependent:

Objective: ABG analysis result (7/12/11): paCO2: 87 O2 Sat: 90 (moderate hypoxemia) Presence of tracheostomy tube Absence of breath sounds upon auscultation Restlessness

Administer medications as indicated.

Collaborative: Administer nebulizer treatments provide humidification ordered.

To treat underlying

conditions.

and as

Nebulizer treatments are used to administer bronchodilators and other medications; humidity helps loosen secretions.

 Tachycardia Pale skin Use of accessory muscle for breathing

Administer oxygen therapy as ordered.

To enhance oxygenation and detect signs of decompensation. Older pts. have a high incidence of chronic cardiac and chronic pulmonary disorders.