Vii
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ASSESSMENT Subjective: patient verbalized “sumasakit ang sugat ko kapag humihinga ako ng malalim” “sumasakit din ang sugat ko kapag bigla akong umuubo” Objective: Patient has Rapid and shallow respirations RR- 25 bpm Oxygen Saturation: 99%
NURSING DIAGNOSIS
PLAN OF CARE
Risk for impaired Independent: Gas exchange related to high Observe respiratory rate/depth. abdominal surgical incision Auscultate breath sounds.
EXPECTED OUTCOME
EVALUATION
Short Term Goal:
Goals met
After 30 minutes of nursing intervention, the client will be able to demonstrate :
After 30 minutes of nursing intervention the client demonstrated:
Assist patient to turn, cough, and deep breathe periodically.
Effective breathing
Effective breathing
Show patient how to splint incision when coughing.
Proper splinting when coughing
Proper splinting when coughing
Instruct effective breathing techniques. Elevate head of bed, maintain low-Fowler’s position.
Long Term Goal:
After 8 hours of nursing intervention the client Support abdomen when coughing, will have an improved breathing pattern as ambulating. evidenced by a normal respiratory rate (12Collaborative: 20bpm).
Assist with respiratory treatments, e.g., incentive spirometer, oxygen inhalation.
Administer analgesics before breathing treatments/ therapeutic activities. 29
After 8 hours of nursing intervention the client established an improved breathing pattern. RR- 20bpm
30
NURSING DIAGNOSIS
PLAN OF CARE
Risk for impaired Independent: Gas exchange related to high Observe respiratory rate/depth. abdominal surgical incision Auscultate breath sounds.
EXPECTED OUTCOME
EVALUATION
Short Term Goal:
Goals met
After 30 minutes of nursing intervention, the client will be able to demonstrate :
After 30 minutes of nursing intervention the client demonstrated:
Assist patient to turn, cough, and deep breathe periodically.
Effective breathing
Effective breathing
Show patient how to splint incision when coughing.
Proper splinting when coughing
Proper splinting when coughing
Instruct effective breathing techniques. Elevate head of bed, maintain low-Fowler’s position.
Long Term Goal:
After 8 hours of nursing intervention the client Support abdomen when coughing, will have an improved breathing pattern as ambulating. evidenced by a normal respiratory rate (12Collaborative: 20bpm).
Assist with respiratory treatments, e.g., incentive spirometer, oxygen inhalation.
Administer analgesics before breathing treatments/ therapeutic activities. 29
After 8 hours of nursing intervention the client established an improved breathing pattern. RR- 20bpm
30
