Assessment
 Subjective
Data:
-"Parang
hindi ako
makahinga
nang
maayos,
hirap ako
huminga at
parang may
bigat sa
dibdib ko."
As
verbalized
by the
patient
 Objective
Data:
-Vital Signs:
BP- 100/60
RR- 26
HR- 118
T- 37.4C
SPO2- 75%
-Nasal
Flaring
-Use of
accessory
Diagnosis
 Impaired
gas
exchange
related to
ventilationperfusion
imbalance.
Planning
 Within the
series of
nursing
interventions,
the patient
will
demonstrate
improved
respiratory
ventilation
and ease of
breathing.
Intervention
 Received
patient on
bed with on
going IVF
regulated at
indicated
drops per
minute.
Rationale
 Ensuring
intravenous
fluids (IVF) are
regulated at the
correct rate
maintains fluid
balance,
prevents
dehydration or
overload, and
supports
hemodynamic
stability,
ensuring
therapeutic
effectiveness
without
complications.
 Established
rapport.
 Building rapport
with the patient
fosters trust,
encourages
open
communication,
and promotes a
positive nursepatient
relationship.
Evaluation
 Following a
series of
nursing
interventions,
the patient
will
demonstrate
improved
ventilation
and adequate
oxygenation
of tissues
within
client’s usual
parameters
and absence
of symptoms
of respiratory
distress.
muscles
when
breathing
 Vital signs
taken and
recorded.
 Monitoring and
recording vital
signs provide a
baseline and
ongoing data to
assess the
patient’s
current health
status. This is
crucial for
identifying any
abnormalities,
tracking the
progress of the
patient, and
detecting early
signs of
deterioration or
improvement in
their condition.
 Elevated the
head of bed
and position
 Elevation or
upright position
facilitates
respiratory
-Fast but
shallow
breathing
client
appropriately.
function by
gravity;
however, client
in severe
distress will
seek position of
comfort.
 Encouraged
frequent
position
changes and
deep
breathing
exercises.
 Promotes
optimal chest
expansion and
oxygen
diffusion.
 Encouraged
adequate rest
and limit
activities to
within client
tolerance.
Promoted
calm and
restful
environment.
 Helps limit
oxygen needs
and
consumption.
 Kept the
environment
allergen and
 This reduce the
irritant effect of
dust and
pollutant
free.
chemicals on
airways.
 Advised
oxygenconserving
techniques
[e.g. eating
small meals,
performing
small
movements]
 helps the
patient optimize
oxygen use,
reduce
shortness of
breath, and
prevent fatigue,
promoting
better
respiratory
efficiency and
comfort.
 Emphasized
the
importance
of nutrition
 This improved
stamina and
reducing the
work of
breathing.
 Administered
medications
as indicated.
 Pharmacological
agents are
varied, specific
to the client,
but generally
used to prevent
and control
symptoms,
reduce
frequency and
severity of
exacerbations,
and improve
exercise
intolerance.
 Care
rendered and
needs
attended.
 Care was
rendered and
the patient's
needs were
attended to in
order to provide
holistic support,
promote
comfort, and
ensure timely
interventions,
contributing to
overall patient
well-being and
recovery.