Pathophysiology from
textbook
Medical Diagnosis
Bronchitis
Goal Met
Partially
Met
Not Met
Nursing Diagnosis
Impaired Gas
Exchange
Goal
Pt will have improved respiratory rate of 12 to 20
bpm within 30 minutes post intervention.
Complications and information
to report to HCP
Increase in respiratory distress
Increase in temperature
Decrease in PO2 level
Assessment data to support nursing diagnosis
Chest Discomfort O2 3l/nc Husband Smokes
Decreased lung sounds LLLobe
Progressive difficulty breathing
102.2F 148/74, 116, 26
PO2 87% RA
Scientific Rationale
1. Promotes optimal chest expansion
and drainage of secretions
2.Helps to mobilize lung secretions an
improve expectoration
3. To treat underlying condition and
improve respiratory status.
4. Helps limit oxygen needs
5. Promotes optimal chest expansion
and mobilizes lung secretions
Referrals and or Teaching
needs
**Highlight interventions
actually perform with highlighter
and evaluate
Diagnostic exams,Laboratory test and
results relating to nursing diagnosis
Consolidation in LLLobe - CXR
WBC 11,000
Nursing Interventions **
1. *Maintain elevated head of bed.
2. *Encourage and maintain
adequate fluid intake
3. Administer and monitor
prescribed medication
4.*Encourage adequate rest and
promote calm environment
5.*Encourage cough and deep
breathing at least every 2 hours
Evaluation of Interventions performed
1. States no shortness of breath, respirations regular
and unlabored.
2. Fluid intake 1000 mls in 24 hours, productive thin
clear sputum
3. No adverse reaction to medications, fever, or
worsening respiratory symptoms
4. PO2 97% on oxygen 3L/nc
5. Performed deep breathing and productive cough
with difficulty.
N:ADN/Freshmen/Spring/RNSG2561/Concept Care Map Template Level II
11/12