CUES NURSING SCIENTIFIC BASIS GOAL & NURSING ACTIONS & RATIONALE OF EVALUATION

DIAGNOSIS OUTCOME NURSING ORDERS NURSING ORERS

CRITERIA
Impaired gas Perfusion to the After 8 hours of Goal – met
S- exchange r/t myocardium is often nursing intervention when patient
“nahihirapang ventilation impaired with left the patient will be Independent: was able to
huminga ang perfusion ventricular failure, able to: demonstrate
aking anak” imbalance. and especially with 1. Elevated head of bed/ 1. To maintain airway improved
as verbalized cardiac hypertrophy. 1. Demonstrate position client ( Deonges; 2006: ventilation and
by the As the amount of improved appropriately, provide P267) adequate
patients blood ejected from ventilation airway adjuncts and oxygenation of
mother. the left ventricle and adequate suction as indicated. tissues by HBGs
diminishes, oxygenation within clients
hypostatic pressure of tissues by 2.Encouraged frequent normal limits
builds in the HBGs within deep breathing/ coughing 2. Promotes optimal
pulmonary venous clients normal exercises. chest expansion and
system and results in limits drainage of
O- Patient is fluid-filled alveoli secretions.
restless. Rate, and pulmonary 2. Participate in (Deonges;2006:P26
rhythm and congestion. treatment 3. auscultated breath 8)
depth of (Ignatavicius; 2006: regimen(e.g, sounds noting crakles,
breathing is p753) breathing wheezes 3. Reveals presence
abnormal. exercises, of pulmonary
Nasal flaring effective congestion/ collection
was noted. coughing, use of secretion,
of oxygen) Collaborative: indicating need for
V/S: within level of further intervention.
BP: 130/100 ability/situatio 1. Assisted with (Deonges;2006:
mmHg n. procedures as individually P268)
T: 36.6 ˚C indicated ( e.g.,
P: 160 bpm 3. Verbalize transfusion, phlebotomy,
R: 60 cpm understanding bronchoscopy 1. to improve
of causative respiratory function/
factors and oxygen-carrying
appropriate capacity
intervention. (Deonges;2006:P268)