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CUES
NEEDS
NURSING
DIAGNOSIS
Subjective:
Nalisdan jus log
hinge. as verbalized
by the patient.
A
C
T
I
V
I
T
Y
Impaired gas
exchange related to
impaired diffusion of
Gases Associated
with Accumulation of
Fluid in the
Pulmonary Interstitial
and Alveoli
Objective:
1.
2.
3.
4.
5.
Dyspnea
Slow respiration
Restlessness
Cough
Adventitious
breath sounds
(wheezing)
Vital Signs:
BP - 110/70
T - 37.PR - 85
RR - 12
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N
GOAL OF CARE
NURSING
INTERVENTIONS
EVALUATION
overall : GOAL
PARTIALLY MET
(GOAL NOT MET)
Patient was not able
to:
1. Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients
usual parameters
and absence of
symptoms of
respiratory
distress
Positive signs of:
Dyspnea
2. Slow respiration
3. Restlessness
4. Cough
5. Adventitious
breath sounds
(wheezing)
RR - 12
CUES
NEEDS
NURSING
DIAGNOSIS
Subjective:
Nalisdan jus log
hinge. as verbalized
by the patient.
A
C
T
I
V
I
T
Y
Impaired gas
exchange related to
impaired diffusion of
Gases Associated
with Accumulation of
Fluid in the
Pulmonary Interstitial
and Alveoli
Objective:
1.
2.
3.
4.
5.
Dyspnea
Slow respiration
Restlessness
Cough
Adventitious
breath sounds
(wheezing)
Vital Signs:
BP - 110/70
T - 37.PR - 85
RR - 12
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N
GOAL OF CARE
NURSING
INTERVENTIONS
EVALUATION
overall : GOAL
PARTIALLY MET
(GOAL NOT MET)
Patient was not able
to:
1. Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients
usual parameters
and absence of
symptoms of
respiratory
distress
Positive signs of:
Dyspnea
2. Slow respiration
3. Restlessness
4. Cough
5. Adventitious
breath sounds
(wheezing)
RR - 12
CUES
NEEDS
NURSING
DIAGNOSIS
Subjective:
Nalisdan jus log
hinge. as verbalized
by the patient.
A
C
T
I
V
I
T
Y
Impaired gas
exchange related to
impaired diffusion of
Gases Associated
with Accumulation of
Fluid in the
Pulmonary Interstitial
and Alveoli
Objective:
1.
2.
3.
4.
5.
Dyspnea
Slow respiration
Restlessness
Cough
Adventitious
breath sounds
(wheezing)
Vital Signs:
BP - 110/70
T - 37.PR - 85
RR - 12
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N
GOAL OF CARE
NURSING
INTERVENTIONS
EVALUATION
overall : GOAL
PARTIALLY MET
(GOAL NOT MET)
Patient was not able
to:
1. Demonstrate
improved
ventilation and
adequate
oxygenation of
tissues by ABGs
within clients
usual parameters
and absence of
symptoms of
respiratory
distress
Positive signs of:
Dyspnea
2. Slow respiration
3. Restlessness
4. Cough
5. Adventitious
breath sounds
(wheezing)
RR - 12