NANDA-I Dx
GOALS
P: Activity
intolerance
By end of week
the patient will
not be short of
breath and
cough will be
gone
E: r/t
Shortness of
breath
S: (AEB)
Nasal canula,
Labored
breathing and
productive
cough
EPXECTED
Nsg INTERVENTION
OUTCOME
*Patient will be *mometasone/formoterol
able to ambulate
will be administered
to restroom and *Confirm patients is using
stop once in
nasal canula, and 2L/h is
between to
the correct order
catch breath
*Educate patient on
within 2 hours.
proper use of walker
*Patient will
demonstrate
proper use of
walker within an
hour
RATIONALE
*medication is
used to help
open bronchial
tubes which will
assist in proper
gas exchange
and reduce
cough
*Nasal canula at
2L/h will help
patients O2
saturation stay
within range and
limit shortness
of breath
*Proper use of
walker will help
the patient
ambulate and
strengthen lungs
and be able to
ambulate
further.
Reference:
Ackley et al.,
2019, p. 350-356