Name of Patient: Gabucan, Raymonda Age: 50 Rm:________________ Hospital No.

________ Diagnosis/Impression: Ovarian New Growth Probably Malignant Attending Physician: Dr. Paulo

NURSING CARE PLAN

CUES Subjective: Maglisod ko ug ginhawa labi na kung mutindog ko as verbalized by the patient. Objective: V/S: T= 36.6 C PR= RR= BP= Restless Weak Enlarged Abdomen DIAGNOSIS Difficulty in breathing related to abdominal pressure as evidenced by fast breathing. PLANNING At the end of 3 days of nursing intervention the client will be able to maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range. INTERVENTION Independent: RATIONALE EVALUATION At the end of 3 days of nursing intervention the client will be able to maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range. -Partially met-

Monitor respiratory Rapid shallow rate, depth, and respirations/dyspn effort. ea may be present because of hypoxia and /or fluid accumulation in abdomen.

Auscultate breath sounds, noting crackles, wheezes, rhonci. Keep head of bed elevated. Position on sides.

Indicates developing complications, increasing risk of infection. Facilitates breathing by reducing pressure on the diaphragm, and minimizes risk of aspiration of secretions.

Encourage frequent

repositioning and deep-breathing exercises as appropriate. Collaborative: Monitor serial ABGs, pulse oximetry, vital capacity ,measure ments, chest xrays. Provide supplemental O2 as indicated.

Aids in lung expansion and mobilizing secretions.

May be necessary to treat/ prevent hypoxia. If respirations/ oxygenation inadequate, mechanical ventilation may be required.