ASSESSMENT

NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
Subjective:
-Tatlong araw
na kong
nahihirapan
huminga, as
verbalized by
the patient.
-Sumasakit
yung dibdib ko
nitong mga
nakaraang
araw, as
verbalized by
the patient

Objective:
(+) Crackles on
lower left lung
field
(+) subcostal
retractions
-non-
productive
cough
-(+) chest pain
Impaired gas
exchange
related to thick
viscous
secretion.
Short-term:
After 6 hours of
nursing
intervention, the
patient will:
- Report
absence
of/decreased
dyspnea.
- Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by
ABGs within
acceptable
ranges.

Long-term:
After 3 days of
nursing
intervention, the
patient will:
- Be free of
Independent:
- Assess for
dyspnea (using
010 scale),
tachypnea,
abnormal/diminis
hed breath
sounds,
increased
respiratory effort,
limited chest wall
expansion, and
fatigue.
- Evaluate change
in level of
mentation. Note
cyanosis and/or
change in skin
color, including
mucous
membranes and
nail beds.
- Demonstrate/
encourage
pursed-lip
breathing during
exhalation,
especially for

- Use of a scale
to evaluate
dyspnea helps
clarify degree of
difficulty and
changes in
condition.




- Accumulation of
secretions/
airway
compromise
can impair
oxygenation of
vital organs and
tissues.
- Creates
resistance
against out
flowing air to
prevent
After
nursing
intervention,
the patient
should:
-Report
absence of/
decreased
dyspnea.
-Demons-
trate
improve
ventilation
and
adequate
oxygenation
of tissues by
ABGs within
acceptable
ranges.
- Demons-
trate
absence of
the
symptoms of
After
nursing
interven-
tion, the
patient:
- Has
absence
of/
decreased
dyspnea
-Demon-
strated the
behaviors
to improve
ventilation
and
adequate
oxygena-
tion of
tissues.
- Demons-
trated the
absence of
the
symptoms

ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
-DOB
-V/S as taken:
BP= 120/70
mmHg
PR= 62 bpm
RR= 26 bpm
Temp= 36.4C
symptoms of
respiratory
distress.
patients with
fibrosis or
parenchymal
destruction.








- Promote bed rest/
limit activity and
assist with self-
care activities as
necessary.







- Monitor serial
ABGs/pulse
oximetry.


collapse/
narrowing of
the airways,
thereby helping
distribute air
throughout the
lungs and
relieve/ reduce
shortness of
breath.
- Reducing
oxygen
consumption/
demand during
periods of
respiratory
compromise
may reduce
severity of
symptoms.
- Decreased
oxygen
content (Pao
2
)
and/or
saturation or
respiratory
distress.
of
respiratory
distress.


ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA








- Provide
supplemental
oxygen as
appropriate.







Collaborative:
- Administer
medications as
prescribed.

- Nebulize the
patient.
increased
Paco
2
indicate
need for
intervention/
change in
therapeutic
regimen.
- Aids in
correcting the
hypoxemia
that may occur
secondary to
decreased
ventilation/
diminished
alveolar lung
surface

- To improve
patients
condition
medically.
- To dilate
airway


ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
Subjective:
-Tatlong araw
na kong
nahihirapan
huminga, as
verbalized by
the patient.

Objective:
(+) Crackles on
lower left lung
field
(+) subcostal
retractions
-non-
productive
cough
-V/S as taken:
BP= 120/70
mmHg
PR= 62 bpm
RR= 26 bpm
Temp= 36.4C
Ineffective
airway
clearance
related to
retained secre-
tions in the
respiratory
tract secondary
to bacterial
infection as
evidenced
by crackles
upon
auscultation.
Short-term:
After 6 hours of
nursing
intervention, the
patient will:
- Maintain
patent airway.
- Expectorate or
clear
secretions
readily.
- Verbalize
understanding
of cause(s)
and
therapeutic
management
regimen.

Long-term:
After 3 days of
nursing
intervention, the
patient will:
- Demonstrate
Independent:
- Monitor
respirations and
breath sounds.


- Evaluate patients
cough/ gag reflex
and swallowing
ability.
- Position the
patient
appropriately
(head elevated,
Fowlers/ Semi-
fowlers, side-
lying)
- Suction naso/
tracheal/ oral prn.

- Indicative of
respiratory
distress and/or
accumulation
of secretions.
- To determine
ability to
protect own
airway.
- To open/
maintain open
airway in at
rest or
individual


- To clear airway
with excessive
or viscous
secretions are
blocking
airway/ patient
is unable to
swallow or
After nursing
intervention,
the patient
should:
- Maintain
patent
airway.
- Expec-
torate
secretions
readily.
- Verbalized
under-
standing of
cause(s)
and
therapeutic
manage-
ment
regimen.
- Demons-
trate
absence/
reduction
of
After
nursing
interven-
tion, the
patient:
- Has
patent
airway
but not
maintaine
d.
- Under-
stood the
causes
and
thera-
peutic
manage-
ment.
- Demon-
strated the
behaviors
to improve
or maintain
clear

ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
absence/
reduction of
congestion
with breath
sounds clear,
respirations
noiseless,
improved O2
exchange.
- Demonstrate
behaviors to
improve or
maintain clear
airway.


- Encourage deep
breathing and
coughing
exercises.


- Increase fluid
intake.





- Support reduction/
cessation of
smoking.
- Auscultate breath
sounds and
assess air
movement.
- Monitor vital signs
cough
effectively.
- To improve
breathing
pattern and to
easily
expectorate
secretions.
- Hydration can
help liquefy
viscous
secretions and
improve
secretion
clearance.
- To improve
lung function.

- To ascertain
status and
note progress.

- To assess the
patients
present
congestion
with breath
sounds
clear,
respirations
noiseless,
improved
O2
exchange.
- Demons-
trate
behaviors
to improve
or maintain
clear
airway.

ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA

- Observe signs
and symptoms of
infection.


- Monitor and
document lab
results like chest
x-rays, CBC and
others.

Collaborative:
- Administer
medications as
prescribed:
cefoxitin,
celecoxib,
azithromycin,
NAC,
paracetamol,
Aeknil.
- Nebulize the
patient.
condition.
- To indentify
infectious
process/
promote timely
intervention.
- To determine
improvements
or changes in
patients
condition.


- To improve
patients
condition
medically.





- To dilate
airway.


ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
Subjective:
-Tatlong araw
na kong
nahihirapan
huminga, as
verbalized by
the patient.
-Sumasakit
yung dibdib ko
nitong mga
nakaraang
araw, as
verbalized by
the patient

Objective:
(+) Crackles on
lower left lung
field
(+) subcostal
retractions
-non-
productive
cough
-(+) chest pain
Ineffective
breathing
pattern related
to acute
infection and
decreased lung
capacity
Short-term:
After 6 hours of
nursing
intervention, the
patient will:
-Establish a
normal, effective
respiratory
pattern as
evidenced by
absence of
cyanosis and
other signs and
symptoms of
hypoxia with
ABGs within
clients normal or
acceptable
range

Long-term:
After 3 days of
nursing
intervention, the
patient will:
Independent:
-Monitor respiratory
status including
vital signs, breath
sounds
and skin color

-Administer oxygen
at lowest
concentration
indicated and
prescribed
respiratory
medications





-Monitor ABG level
and oxygen
saturation as
needed



-Respiratory
assessment
helps gauge the
patients
severity and
whether if it is
progressing.
-For
management of
underlying
pulmonary
condition,
respiratory
distress or
cyanosis
and to provide
relief from
symptoms of
hypoxemia and
hypoxia
- ABG levels
and continuous
pulse oximetry
measures the
blood oxygen
content and are
good indicators
After nursing
intervention,
the patient
should:
- Establish a
normal,
effective
respiratory
pattern.
- Demons-
trate
absence of
the
symptoms
of
respiratory
distress
After
nursing
interven-
tion, the
patient:
- Has a
normal,
effective
respire-
tory
pattern.
- Have a
good
respire-
tory
function.


ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
-DOB
-V/S as taken:
BP= 120/70
mmHg
PR= 62 bpm
RR= 26 bpm
Temp= 36.4C

-Promote good
respiratory
function.




- Place the patient
in semi fowlers
position and place
the diaphragm in
proper position to
contract




Collaborative:
- Administer
medications as
prescribed.

- Nebulize the
patient.
of the lungs
ability to
oxygenate the
blood.
-To increase
chest
expansion, to
alleviate
dyspnea and to
promote
physiological
and
psychological
ease of maximal
inspiration


- To improve
patients
condition
medically.
- To dilate
airway.


ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
Subjective:
- Madali ako
mapagod pag
tumatayo
ako, as
verbalized by
the patient.
- Nahihirapan
akong
maglakad, as
verbalized by
the patient.

Objective:
- General
weakness
- Chest pain
- DOB
-V/S as taken:
BP= 120/70
mmHg
PR= 62 bpm
RR= 26 bpm
Temp= 36.4C

Activity
intolerance
related to easy
fatigability as
evidenced by
difficulty of
breathing
Short- Term:
After 6 hours of
nursing
intervention, the
patient will be
able to manage
activity within
individual limits.

Long-Term:
After 3 days of
nursing
intervention, the
patient will be
able to perform
ADL without any
signs of fatigue.
Independent:
- Encourage patient
to deal with
contributing
factors and
manage activities
within individual
limits.



- Assess patient
level of mobility.






- Reduce intensity
level or
discontinue
activities that
cause undesired
physiological

- To help the
patient
overcome his
weaknesses
and encourage
him to make
himself feel
better with the
help of nurses
too.
- Aids in
defining what
patient is
capable of
which is
necessary
prior to setting
realistic goal.
- To promote
relaxation/
rest.
After nursing
intervention
the patient
should:
- Know how
to manage
activity
within
individual
limits.
- Perform
activities of
daily living
without any
signs of
fatigue.
After
nursing
interven-
tion, the
patient:
- Is able to
walk
without
pain.
- Tolerated
the daily
activities
without
signs of
fatigability

ASSESSMENT
NURSING
DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE
EVALUATION
STANDARD CRITERIA
changes.
- Assess nutritional
status.



- Educate the
patient about the
different
regimens/
managements to
maintain
adequate energy,
manage activities
and perform
activity of daily
living without
fatigability.

- Adequate
energy
reserves are
required for
activities.
- To help the
patient
perform
activity of daily
living without
easy
fatigability and
to make him
enjoy his life/
stay in the
hospital.