Mrs. G.M.C.

52 years old; Married; G10P0

Address: Carolina, Naga City

Admitting Diagnosis: CAP HR; ESRD HTNephrosis

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Independent
 Dyspnea Impaired Breathing After 6 hours of nursing  Assess patient’s After 6 hours of nursing
 Pt appears to be Pattern intervention patient will general condition interventions patient has
pale be able to:  Monitor and regained energy and was
 Fatigue  Regain energy record VS able to demonstrate
 Use of accessory  Verbalize  Assess patient’s effective breathing
muscles understanding capillary refill pattern.
and demonstrate  Encourage patient
effective to do deep
breathing breathing exercise
technique Dependent
 Administered
nebulizer per
doctor’s order
 Position patient to
semi-fowler’s
position
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Independent
 Productive cough Ineffective Airway After 6 hours of nursing  Assess patient’s After 6 hours of nursing
with sputum Clearance related to intervention, the patient’s condition intervention, the patient’s
production Increase sputum respiration will improve  Monitor and respiration improved and
 Dyspnea production and difficulty in breathing record VS difficulty in breathing shall
 Changes in rate will be relieved  Auscultate lung have been relieved.
and depth of fills
respiration  Assist patient to
 Adventitious change position
sound heard upon every 30 minutes
auscultation at  Elevate HOB and
patient’s right align head of
lung patient in the
middle
 Provide health
teachings
regarding
effective coughing
and deep
breathing exercise
 Advise to increase
fluid intake
Dependent
 Administer
medication as
ordered
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
 Subjective: Activity intolerance After 6 hours of nursing Independent
“Maluluya ang related to general interventions, the patient  Bedside care done After 6 hours of nursing
pagmati ko.” As weakness will report/demonstrate a  Monitor and intervention patient was
verbalized by the measurable increase in record VS able to:
patient tolerance activity with  Encouraged  Identify methods
 Body malaise absence of dyspnea and patient to balance to reduce activity
noted excessive fatigue rest and activity intolerance.
 Dyspnea  Provide  Exhibit tolerance
diversional during physical
activities such as activity
reading
newspaper and
watching TV
 Advise patient to
perform passive
exercises
 Assist patient to
comfortable
position
 Provide adequate
rest period
 Keep patient safe
on bed
Dependent
 Administer
medication per
doctor’s order
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
 Restlessness Impaired Gas Exchange After 6 hours of nursing Independent After 6 hours of nursing
 Dyspnea related to altered delivery interventions, the patient  Assessed interventions, the patient
of oxygen will demonstrate respiratory rate, was able to:
participate in actions to depth, and ease.  maximize
maximize oxygenation.  Observed color of oxygenation.
skin, mucous
membranes, and
nail beds, noting
presence of
peripheral
cyanosis (nail
beds) or central
cyanosis
(circumoral).
 Assessed mental
status.
 Encouraged to
increase fluid
intake.
 Maintained
bedrest.
Encourage use of
relaxation
techniques and
diversional
activities.
 Elevated head
and encourage
frequent position
changes, deep
breathing, and
effective
coughing.
 Assessed anxiety
level and
encourage
verbalization of
feelings and
concerns.
 Observed for
deterioration in
condition, noting
hypotension,
copious amounts
of bloody sputum,
pallor, cyanosis,
change in LOC,
severe dyspnea,
and restlessness.
 Monitored
oxygen saturation
as per doctors’
order.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Deficient knowledge
After 6 hours of nursing  Discuss debilitating aspects
interventions, the patient of disease, length of
related to will: convalescence, and recovery
misinterpretation of  verbalize expectations. Identify self-
understanding of care and homemaker needs.
information condition/disease.  Provide information in
 Initiate necessary written and verbal form.
lifestyle changes  Reinforce importance of
continuing
effective coughing and deep-
breathing exercises.
 Emphasize necessity for
continuing antibiotic therapy
for prescribed period.
 Outline steps to enhance
general health and well-
being: balanced rest and
activity, well-rounded diet,
avoidance of crowds during
cold/flu season and persons
with URIs.
 Identify signs and symptoms
requiring notification of
health care
provider: increasing
dyspnea, prolonged fatigue,
weight loss, fever,
chills, persistence of
productive cough, changes
in mentation.