b.

Actual Nursing Care Plan

CUES Nursing
Goals &
Diagnosis Interventions Rationale Evaluation
Subjective Objective Objectives

“galisod  Nasal Ineffective At the end of30 INDEPENDENT: At the end

man ko ug flaring breathing pattern minutes to 1  Elevate head of the - Promotes ease of of 1 hour,
ginhawa”, noted related to hour, client will bed and instruct to do maximal inspiration, goals were
as  Irritability hyperventilation as be able to deep breathing allowing optimal lung partially met
verbalized as noted evidenced by breathe exercises. expansion since the
by the  Tachypne tachypnea with RR comfortably,  Maintain calm attitude - This will limit client’s patient was
patient a-RR: 55 of 55 cpm with ability to while dealing with client level of anxiety. able to
cpm as performed & significant others. perform
noted pursed-lip  Assess color of the skin - To determine pursed-lip
breathing and and oral mucosa cyanosis breathing
use of including the tongue. but still in
relaxation  Encourage client to use - Relaxation slightly
techniques. relaxation technique minimizes oxygen ineffective
like diversional demand breathing
activities pattern.
 Teach client and - It helps client to be
significant others with aware of the
the contributing factors condition at it
of the condition. reduces the risk for
reoccurrence of
ineffective breathing
COLLABORATIVE: episodes.
- To increase
 Provide oxygen
oxygenation,
inhalation as ordered.
improve ventilation,
- O2 inhalatin @ 2
and reduce
LPM via nasal
dyspnea.
canula
- Aids in muscle
 Administer medication contractility thus
as prescribed. decreasing cardiac
terbutaline (Bricanyl) output preventing
syrup 5 ml TID PO cardiac overload.

29
 b. Actual Nursing Care Plan

CUES Nursing
Goals &
Diagnosis Interventions Rationale Evaluation
Subjective Objective Objectives

“gakalipong  Impaired
slightly weak At the end INDEPENDENT: At the end of
ko pag as noted gas of 30 30 minutes to
mubangon  restless onexchange minutes to 1  Elevate head of the bed at - Elevation assist 1 hour, goals
ko sa appearance related to hour, client
45
◦ airway patency were partially
akong  pale and altered will be able
 Encourage patient to do
- Facilitates optimal met since the
higdaanan” dusky skin delivery of to lung expansion. patient was
deep breathing exercises.
, as color noted oxygen demonstrate - Duskiness and able to
verbalized improvemen  Monitor skin and mucous cyanosis indicate establish
 RR: 55 cpm membrane color.
by the  nasal flaring t of advanced hypoxemia improved
patient. noted ventilation - It helps in limiting ventilation but
and  Encourage adequate rest oxygen need or still
 diaphoresis and limit activities within
adequate consumption. tachypneic
noted client’s tolerance.
oxygenation - Indicative of cerebral with present
 dizziness as .  Monitor level of dysfunction. RR of 47cpm
noted consciousness or mental
status.

COLLABORATIVE:
 Provide oxygen inhalation
as ordered.
-O2 inhalation @ 2 LPM
via nasal canula
 Give medication as
prescribed.
- terbutaline (Bricanyl)
syrup 5ml TID P.O
 Monitor O2 saturation
using pulse oximeter
- To increase
oxygenation, improve
ventilation, and
decrease dyspnea.
- To cause
bronchodilation.
- O2 saturation of less
than 90% indicates
significant
oxygenation
problems.

30
 b. Actual Nursing Care Plan

CUES Nursing
Goals &
Diagnosis Interventions Rationale Evaluation
Subjective Objective Objectives

NO CUES  Slow Ineffective At the end INDEPENDENT: At the end of

capillary refill tissue of 30  Note baseline data - To determine any 1 hour, goals
CRT:3-4 perfusion minutes-1 like vital signs and mental unusualities. were partially
seconds as related to hour, patient status. met since the
noted decreased will be able  Encourage quiet, - It will conserve patient shows
 Nasal oxygen to show sign restful atmosphere. energy and lowers improve
flaring noted pumped by of adequate oxygen demands of tissue
 Tachypn the heart tissue tissues. perfusion but
ea perfusion  Caution client to - To prevent potential with slow
RR: 55 cpm with good avoid activities that health problems capillary refill
as noted capillary increase cardiac work from occurring. time of 3
refill time load. - To promote blood seconds.
 Encourage client circulation.
to ambulate within
tolerance. - Failure of the heart
 Monitor respiration to pump can lead to
including work of respiratory distress.
breathing.

COLLABORATIVE:
- Oxygen therapy
 Provide oxygen
helps decrease
inhalation as ordered.
dyspnea and
-O2 inhalation@ 2 LPM
improve ventilation.
via nasal canula
- To increase
 Administer contractility which
medication as prescribed, will lead to increase
-Dopamine ;1 amp + 200 cardiac output
cc D5W via yringe pump
-Dobutamine ;20 ml IVTT

30