Assessment Nursing Inferences Planning Nursing Rationale evaluation

Diagnosis Intervention

“ nihindiko man Self-care After 1 hour of • Determine • Make After 8hours

langmasuklay and deficit continuous individual appropriate of continuous
buhokko at related to nursing strength and technique nursing
malinisangsariliko” impaired intervention the skills of a that will intervention
As verbalized by mobility client will be client. facilitate the client
the client. status as able to perform teaching to safely
manifested self-care develop plan performs (to
Objective: by activity activity within of care maximum
The client intolerance. level of own appropriate ability) self-
appears: ability. to individual care activities.
• Inability to situation.
feed self
independentl
y • To discover
• Inability to • Plan a time for barriers to
dress self listening to the participation
independentl client concern in regimen
y and to work
• Inability to on problem
bathe and solutions.
groom self
independentl
y • Allow sufficient
• Inability to time for
perform dressing and
toileting undressing,
tasks since the task
independentl may be tiring,
 y painful, and
• Inability to difficult.
transfer from
bed to • Plan for
wheelchair person to learn
• Inability to and
ambulate demonstrate
independentl one part of an
y activity before
progressing
further. • To enhance
sense of
• Nurture well-being
individualized
attributes such
as humor,
positive
attitude, faith,
and hope.
Assessment Nursing Inference Planning Nursing Rationale evaluation
diagnosis Intervention

Subjective: Impaired gas After 30 • Identified • To identified After

“nakakramdam exchange minutes of presence of causative 30minutes of
kongpaghiraps related to nursing factors that and nursing
apaghinga ” as pulmonary intervention the could contributing intervention
verbalized by congestion client will contribute to factors. the client
the client. as demonstrate impaired gas demonstrate
manifested improve exchange improved
Objective: by increased ventilation as such as ventilation as
v/s: respiratory evidenced by: environment evidenced by:
BP130/100mm rate. and aging. • Reported
hg • Verbalized • Position client • Positioning a improvem
PR- 72 bpm improveme appropriately client ent of
RR-30 bpm nt of such as appropriately breathing
Temp- breathing elevation of such as pattern
pattern. head. elevation of and
The client • Client • Encourage head helps appear
appears: appears deep to promote rested.
• Confusion rested. breathing maximal
• Somnolenc exercise expansion of
e • Encourage the lungs
• Restlessne adequate rest which
ss and limit enables the
client to
• Irritability activities breath
• Inability to • Provide effectivelyan
move psychological d improves
secretions support by the opening
active listening of the airway
to question
concerns • Promotes
optimal
• Administered chest
oxygen as expansion
prescribed • Oxygen
administratio
n provides
supplementa
l
oxygenation
in the body.
Assessment Nursing Inferen Plannin Nursing Rationale evaluation
diagnos ce g intervention
is

Subjective: Activity After 8 • Assess • To After 8

“ intoleran hours of ability to deter hours of
nahihirapanakongkumiloslalonakapagbumaba ce continuo stand mine continuous
ngonako”as verbalized by the client. related us and curren nursing
to nursing moveme t intervention
Objective: immobilit interventi nt and status the client
y on the degree of and was able to
v/s: seconda client will assisted needs use
BP- 130/100mmhg ry to use needed. associ identified
PR- 72 bpm altered identified ated technique
RR-30 bpm gas techniqu with to
Temp- exchang es to particienhanced
The client appeared: e due to enhance pation activity
• Verbal report of fatigue or weakness pulmona activity in tolerance
• Inability to begin or perform activity ry tolerance desire as
• Abnormal heart rate or blood pressure congesti . d evidenced
(BP) response to activity on. by:
activiti
• Exertional discomfort or dyspnea es. • Client
• Adjust verbal
activities izes
or and
discontin • To uses
ue preven energ
activities t y-
that overex conse
 precipitat ertion. rvatio
e the n
client’sco techni
ndition. ques.

• Teach
methods • To
that conser
facilitate ve
conserva energy
tion of and
energy avoid
such as extra
having 3 consu
minutes mption
of rest of
during oxyge
performin n.
g
activities.

• Assist
client in • To
learning preven
and t
demonstr injurie
ating s.
appropria
te safety
measure
s.
• To
• Encourag enhan
e client to ce
maintain sense
positive of
attitude, well-
suggest being.
use of
relaxatio
n
techniqu
es such
as
visualizat
ion.
Cues Nursing Inference Planning Nursing Rationale Evaluation
Diagnosis Intervention

Subjective: Impaired After 8 hours of • Identified • To identified • Goal met.

gas continous prescence of the After 8
“ exchange nursing factors that causative hours of
nakakaramada related to intervention the could and nursing
m ako ng pulmonary client will contribute to contributing intervention
paghirap sa congestion demonstrate inpaired gas factors the client
paghinga” as as improvement of exchange demonstrate
verbalized by manifested ventilation as such as improvemed
the client. by evidenced by: aging and • Monitoring ventilation
Objective: increased environment as evidence
• Decreased vital signs
respiratory by:
in • Monitor vital reflect the
rate.
rerpiratory signs. client status. • Reported
rate decreased
in RR
• Decreased • These are
crackles the common • Decreased
• Observed signs of crackles
• Client upon
appear restlessness hypoxia
and anxiety auscultation
relaxed and
comfortable • Client
appear
relaxed and
• Signs of
cracles
 indicate comfortable.
accumulatio
• Auscultated n of fluid in
the lungs for the lungs
the sound of
crackles

• Positioning
the client
• Position appropriatel
client y helps to
appropriately promote
such as maximal
elevation of expansion
the head at of the lungs
least 15 which
degree. enables
breath
effectively
and
improves
opening of
the airway.
 • To breathe
easier and
• Encourage to avoid
deep respiratory
breathing distress
exercise
• To limit
oxygen
• Encourage consumptio
adequate n
rest and limit
• Oxygen
activities
administrati
• Provide on provides
oxygen as supplement
ordered al
oxygenation
in the body
Cues Nursing Inference Planning Nursing Rartonale
diagnosis intervention