Date and time Cues Need Nursing Diagnosis Objectives of Care Nursing Evaluation

Interventions
12/18/17 Objective Cues: A Impaired Gas exchange Within the span of 1. Assessed and Goal Partially
due to alveolar/capillary care, the patient record respiratory Met.as evidence
C membrance changes. will be able to: rate, depth. Note by:
10:00am - facial grimace T use of accessory
Maintain muscles,
- Labored I adewuate pursed-lip
R: By the process of respiratory Patient is free
breathing diffusion, the exchange of breathing, from dyspnea
V function as
-patient hooked to oxygen and carbon dioxide inability to speak
I evidenced by or converse. RR: 29
02 @ 2LPM occurs in the absence of
T alveolar-capillary dyspnea, arterial R: Useful in HR 104
- RR: 31 membrane area. The blood gases within evaluating the
-restlessness Y relationship between normal limits, and degree of
ventilation (air flow) and respiratory rate respiratory
-deep respirations -
perfusion (blood flow) within normal distress or
E affects the efficiency of the range. chronicity of the
-Abnormal ABG
gas exchange. Normally disease process.
values X there is a balance between
-Productive E ventilation and perfusion;
Cough present however, certain conditions
R can offset this balance, 2. Elevated head
( Thick yellowish
resulting in impaired gas of bed, assist
to slightly C
exchange. Altered blood patient to assume
greenish phlegm)
I flow from a pulmonary position to ease
- tachycardia embolus, or decreased work of breathing.
S Include periods of
HR: 119 cardiac output or shock can
cause ventilation without time
E
-use of accessory perfusion. Conditions that in prone position
muscle upon cause changes or collapse as tolerated.
respirations. of the alveoli (e.g., Encourage
P atelectasis, pneumonia, deep-slow or
A pulmonary edema, and pursed-lip
adult respiratory distress breathing as
T syndrome) impair individually
T ventilation. (NANDA) needed or
tolerated.
E
R:Oxygen deliver
R y may be
improved by
N
upright position
and breathing
exercises to
decrease airway
collapse, dyspnea,
and work of
breathing.
Note: Recent
research supports
use
of prone position
to increase Pao2.

3. Assessed and
routinely monitor
skin and mucous
membrane color.
R:Cyanosis may
be peripheral
(noted in nailbeds)
or central (noted
around lips/or
earlobes).
Duskiness and
central cyanosis
indicate advanced
hypoxemia.

4. Encouraged
expectoration of
sputum; suction
when indicated.
R:Thick,
tenacious, copious
secretions are a
major source
of impaired gas
exchange in small
airways. Deep
suctioning may be
required when
cough is
ineffective for
expectoration of
secretions.

5. Auscultated
breath sounds,
noting areas of
decreased airflow
and adventitious
sounds.

R: Breath sounds
may be faint
because of
decreased airflow
or areas of
consolidation.
Presence of
wheezes may
indicate
bronchospasm or
retained
secretions.
Scattered moist
crackles may
indicate interstitial
fluid or cardiac
decompensation.
6. Monitored level
of consciousness
and mental status.
Investigate
changes.
R: Restlessness
and anxiety are
common
manifestations of
hypoxia.
Worsening ABGs
accompanied
by confusion/
somnolence are
indicative of
cerebral
dysfunction due to
hypoxemia.

7. Evaluated level
of activity
tolerance. Provide
calm, quiet
environment.
Limit patient’s
activity or
encourage bed or
chair rest during
acute phase. Have
patient resume
activity gradually
and increase as
individually
tolerated.
R:During severe,
acute or refractory
respiratory
distress, patient
may be totally
unable to perform
basic self-care
activities because
of hypoxemia and
dyspnea. Rest
interspersed with
care activities
remains an
important part of
treatment
regimen. An
exercise program
is aimed at
increasing
endurance and
strength without
causing severe
dyspnea and can
enhance sense of
well-being.

8.Monitored
vital signs and
cardiac rhythm
R: Tachycardia,
dysrhythmias, and
changes in BP can
reflect effect of
systemic
hypoxemia on
cardiac function.

9. Inspected skin
for petechiae
above nipple line,
in axilla,
spreading to
abdomen, buccal
mucosa, hard
palate,
conjunctival sacs
and retina.

R: This is the
most characteristic
sign of fat emboli,
which may appear
within 2-3 days
after injury.

10. Administed
supplemental
oxygen if ordered.

R: Decreased
Pa02 and
increased Paco2
indicate impaired
gas
exchange/developi
ng failure.
Date and time Cues Need Nursing Diagnosis Objectives of Care Nursing Evaluation
 Interventions
12/18/16 Objective Cues A Ineffective Airway Clearance Within the span of 1. Auscultated
related to increased production care, the patient breath sounds.
- Presence of C of secretions. will be able t to: Note adventitious
Thick secretions. breath sounds
10:00am T 1. Maintain patent (wheezes,
-Presence of airway with breath crackles, rhonchi).
cough I
sounds clearing
-decreased energy V R: Some degree of
I bronchospasm is
-RR:31 2. Demonstrate present with
-wheezing and T behaviors to obstructions in
crackles noted Y improve airway airway and may or
upon ausculation clearance, e.g, may not be
- cough effectively manifested in
-deep respirations. and expectorate adventitious
E breath sounds
-use of accessory secretions.
such as scattered,
muscle upon X
moist crackles
respirations. E (bronchitis); faint
-tachycardia R sounds, with
expiratory
HR: 119 C wheezes
(emphysema); or
I
absent breath
S sounds
Subjective Cues: (severe asthma).
E
The patient
verbalized “ nag
lisod kog ginhawa P 2. Assessed and
mao nagpa admit monitor
A respirations and
ko. Hanotd karon
mag lisod gihapon T breath sounds,
ko pero mas noting rate and
T sounds
maayo na akong
gibati karon .” E (tachypnea,
stridor, crackles,
R wheezes). Note
inspiratory and
N
expiratory ratio.
R:achypnea is
usually present to
some degree and
may be
pronounced on
admission or
during stress or
concurrent acute
infectious process.
Respirations may
be shallow and
rapid, with
prolonged expirati
on in comparison
to inspiration.
3.Assisted patient
to assume position
of comfort
(elevate head of
bed, have patient
lean on overbed
table or sit on
edge of bed).
R:Elevation of the
head of the bed
facilitates
respiratory
function by use of
gravity; however,
patient in severe
distress will seek
the position that
most eases
breathing.
Supporting arms
and legs with
table, pillows, and
so on helps
reduce muscle fati
gue and can aid
chest expansion.

4.Kept
environmental
pollution to a
minimum such
as dust, smoke,
and feather
pillows, according
to individual
situation.
R:Precipitators of
allergic type of
respiratory
reactions that can
trigger or
exacerbate onset
of acute episode.

5.Encouraged
abdominal or
pursed-lip
breathing
exercises.
R:Provides patient
with some means
to cope
with or control
dyspnea and
reduce
air-trapping.

6.Observedcharact
eristics of
cough (persistent,
hacking, moist).
Assist with
measures to
improve
effectiveness of
cough effort.
R:Cough can be
persistent but
ineffective,
especially if
patient is elderly,
acutely ill, or
debilitated.
Coughing is most
effective in an
upright or in a
head-down
position after
chest percussion.

7. Increased fluid
intake to 3000 mL
per day within
cardiac tolerance.
Provide warm or
tepid liquids.
Recommend
intake of fluids
between, instead
of during, meals.
R:Hydration helps
decrease the
viscosity of
secretions,
facilitating
expectoration.
Using warm
liquids may
decrease
bronchospasm.
Fluids during
meals can increase
gastric distension
and pressure on
the diaphragm.

8.Monitored serial
ABGs, pulse
oximetry, chest
x-ray.
R:Establishes
baseline for
monitoring
progression or
regression of
disease process an
complications. No
te: Pulse
oximetry readings
detect changes in
saturation as they
are happening,
helping to identify
trends before
patient is
symptomatic.
However, studies
have shown that
the accuracy of
pulse oximetry
may be questioned
if patient has
severe peripheral
vasoconstriction.

9.Elevated HOB
R:To decrease
pressure on
the diaphragmand
enhancing
drainage

10. Advised to
reposition and
keep back dry
R: to prevent
infections.

11. Demonstrated
chest
physiotherapy,
such as bronchial
tapping when in
cough, proper
postural drainage.
R:These
techniques will
prevent possible
aspirations and
prevent any
untoward
complications
Date and time Cues Nee Nursing Diagnosis Objectives of Care Nursing Evaluation
d Interventions
12/18/17 Objective Cues: N Imbalanced Nutrition related to Within the span of 1. Ascertained Goal partially met
Dyspnea; sputum production care, the patient understanding of
U As evidence by:
will be able to: individual
-Dyspnea T nutritional needs

-tachycardia R R:To determine 1. Patient’s

Demonstrate signs
informational appetite hasn’t
HR:119 I of increase in needs of client and still increased.
appetite SO.
- weakness T R: patient in acute respiratory
distress is oftern anorectic
-weight loss of I 2. patient
because of dyspnea, sputum
3kg Increased oral 2. Assessed increased oral
O production, and medications. In
fluid intake dietary habits, fluid intake to
- small stature addition, many COPD patients
N recent food intake. 2500ml.
habitually eat poorly, even
BMI: 18.3 Note degree of
A though respiratory insufficiency
Demonstrate difficulty with
Normal range : creates a hypermetabolic state
L increase in muscle eating. Evaluate
18.5–24.9 with increased caloric needs. As
tone. weight and body
- a result, patient often is
- decreased size (mass).
admitted with some degree of
appetite M malnutrition. People who have R:Patient in acute
- decreased oral E emphysema are often thing with respiratory
fluid intake wasted masculature. distress is often
T anorectic because
-poor muscle tone of dyspnea,
A
sputum
B production, and
O medications. In
addition,
L many COPD patie
nts habitually eat
I
poorly, even
C though respiratory
insufficiency
creates a
P hypermetabolic
state with
A
increased caloric
T needs. As a result,
patient often is
T admitted with
E some degree of
malnutrition.
R People who
N have emphysemaa
re often thin with
wasted
musculature.

3. Auscultated
bowel sounds.
R:Diminished or
hypoactive bowel
sounds may
reflect decreased
gastric motility
and constipation (
common
complication)
related to limited
fluid intake, poor
food choices,
decreased activity,
and hypoxemia.

4.Gave frequent
oral care, remove
expectorated
secretions
promptly, provide
specific container
for disposal of
secretions and
tissues.
R:Noxious tastes,
smells, and sights
are prime
deterrents to
appetite and can
produce nausea
and vomiting with
increased
respiratory
difficulty.

5.Encouraged a
rest period of 1 hr
before and after
meals. Provide
frequent small
feedings.
R:Helps
reduce fatigue dur
ing mealtime, and
provides
opportunity to
increase total
caloric intake.

6.Avoided
gas-producing
foods and
carbonated
beverages.
R:Can produce
abdominal
distension, which
hampers
abdominal
breathing and
diaphragmatic
movement and
can increase
dyspnea.

7. Avoided very
hot or very cold
foods.
R:Extremes in
temperature can
precipitate or
aggravate
coughing spasms.

8.Administered
supplemental
oxygen during
meals as
indicated.
R:Decreases
dyspnea and
increases energy
for eating,
enhancing intake.
9.Monitor weight
daily
R: know the status
of patient and
adequeacy of diet
provided.

10. Encouraged to
increase oral fluid
intake
R: providing
hydration can help
better absorption
of food.