Easter College

DEPARTMENT OF NURSING

Patient/age/sex: Microbia/9/F______________________________________ Diagnosis:Hyperventilation may consider Anxiety___________________________________________ Ward: FW2_________________________________

DATA GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

S>”Hinahabol nya po hininga niya STO:Within 2-3 hours of nursing shift, the Dx: STO:Fully met
kanina”, as verbalized by the mother. patient will be able to demonstrate a reduction >Assess vital signs and recorded accordingly >Baseline data >After 2-3 hours of nursing shift, the patient was
in anxiety as evidenced by calm behavior and >Ascertain if client has history of underlying respiratory disorder >To determine whether the client's symptoms are due to a able to demonstrate a reduction in anxiety as
the ability to focus on simple activities such as or if this is a new condition with potential for breathing new respiratory issue or an exacerbation of an existing evidenced by calm behavior and the ability to focus
O>Restlessness observed, fidgeting, and drawing or playing with a toy. problems , or exacerbation of pre-existing problems. condition, ensuring appropriate diagnosis and treatment. on simple activities such as drawing or playing with
difficulty focusing on tasks. a toy.
>Poor eye contact >Note the patient's emotional state >Emotional changes can accompany a condition
>Shallow breathing and rapid precipitate or aggravate ineffective breathing pattern
inhalations. >Assess the client's awareness and cognition >It affects ability to manage own airway and cooperate
Slight chest discomfort reported. with interventions such as controlling breathing
>No signs of cyanosis or extreme >Observe characteristics of >Irregular patterns such as prolonged expiration, periods
distress. LTO:Within 2-3 days of nursing shift, the breathing patterns such as the use of of apnea, and obvious agonal breathing may
patient and the watcher will be able to use accessory muscles for breathing sternal retraction, nasal flaring be pathological >LTO:Fully met
Vital signs taken as follows: learned anxiety-reduction techniques such as and pursed-lip breathing After 2-3 days of nursing shift, the patient and the
T- 37.5 deep breathing independently to manage watcher was able to use learned anxiety-reduction
PR- 112 bpm episodes of anxiety and hyperventilation. >Auscultate and percuss chest, describing presence, absence, >Abnormal breath sounds are indicative of numerous techniques such as deep breathing independently
RR- 34 cpm and character of breath sounds. problems and must be evaluated further. to manage episodes of anxiety and
SPO2- 95% >Observe chest size, shape, and symmetry of movement >Changes of movement in chest wall can impair breathing hyperventilation.
pattern
Tx:
>Monitor respiratory rate and pattern >Continuous monitoring ensures that the intervention’s
NURSING DIAGNOSIS: effectiveness is assessed and provides immediate
Impaired breathing pattern related to feedback for further adjustments if necessary.
anxiety-induced hyperventilation >Provide reassurance and a calm environment: >A quiet, supportive environment helps reduce external
Rationale: A quiet, supportive environment helps reduce stressors, calms the patient, and reduces anxiety, which
PATHOPHYSIOLOGY: external stressors, calms the patient, and reduces anxiety, can help normalize breathing patterns.
which can help normalize breathing patterns.

>Encourage and demonstrate deep breathing exercises >Deep breathing helps to regulate the autonomic nervous
system and reduces the fight-or-flight response, which can
alleviate hyperventilation
>Provide comforting distractions (e.g., toys, books) >Distractions help shift focus from anxiety and
hyperventilation, aiding in relaxation and reducing stress
>Positioning for comfort: >Keeping the child in a comfortable, upright position helps
facilitate easier breathing and minimizes feelings of
breathlessness.
>Administer prescribed anxiolytics or other medications as >Medication may be needed for immediate relief of
needed (e.g., lorazepam) anxiety if the child’s symptoms are severe and not
improving with non-pharmacological interventions.
>Collaborate with respiratory therapy (if needed) >If hyperventilation continues, respiratory therapy may
provide additional support, such as oxygen therapy, or
assist with specialized breathing techniques.
>Monitor oxygen saturation and vital signs >Monitoring oxygen saturation ensures the patient is not
 hypoxic and allows for timely intervention if oxygen levels
fall below acceptable thresholds (typically below 92%).

Edx:
>Teach the patient and family deep breathing techniques >Deep breathing exercises can be utilized in moments of
stress or anxiety to help prevent hyperventilation
episodes.
>Educate the child and the watcher how to recognize early >Early recognition of anxiety can lead to faster
signs of anxiety intervention and a reduction in hyperventilation episodes.
It empowers the child to manage their symptoms
proactively
>Encourage regular practice of relaxation techniques: >Techniques such as listening to calming music, engaging
in light physical activity (if appropriate), or engaging in
hobbies can help manage stress and anxiety.
>Explain when to seek further help >Educating the family on when to seek help ensures
prompt medical intervention if the condition worsens or if
there are signs of distress, such as chest pain or
confusion.
 Easter College
DEPARTMENT OF NURSING

Patient/age/sex: Bacteria/42/F_______________________________________________ Diagnosis:________________________________________________________ Ward:

_________________________________

DATA GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

S>”Maghook daw po sila ulit ng dugo STO:Within 3-4 hours of the nursing shift, the STO:Fully met
sakin mamaya after 1 hour” as verbalized patient will complete the blood transfusion Before Blood Transfusion: >After 3-4 hours of the nursing shift, the patient was
by the patient without complications, and vital signs will able to complete the blood transfusion without
>Verify blood product >Confirming that the correct blood type (A Rh positive) is complications, and vital signs will stabilize, with no
>Patient reports prolonged menstrual stabilize, with no signs of transfusion reactions.
bleeding (23 days) with heavy flow and ordered and compatible with the patient prevents signs of transfusion reactions.
passing clots. transfusion errors and ensures patient safety.

>Assess baseline vital signs >Establishing baseline vital signs before the transfusion
provides a reference point to detect any changes during
O>Pale skin, particularly in the During Blood Transfusion: the procedure, allowing for early identification of
conjunctiva and nail beds (signs of complications.
anemia). >Monitor for delayed transfusion reactions: >Educating the patient on how to identify signs of delayed
>Restlessness and fatigue observed reactions (fever, rash, jaundice) empowers them to seek
>With 1 pack of RBC Type A Rh+ medical help if needed, ensuring prompt intervention if LTO:Fully met
ordered by the physician LTO:Within 2-3 days after the transfusion, the complications occur. >After 2-3 days after the transfusion, the patient
patient will demonstrate improved blood >Monitor for signs of fluid overload: >Signs such as swelling, shortness of breath, or was able to demonstrate improved blood volume
Vital Signs taken as follows: volume and hemoglobin levels, report a increased blood pressure indicate fluid overload, which and hemoglobin levels, report a decrease in
T-36. decrease in symptoms of anemia (fatigue, can be a complication of blood transfusions and requires symptoms of anemia (fatigue, dizziness), and
PR-118bpm dizziness), and improve their overall sense of prompt intervention. improve their overall sense of well-being.__
RR-18cpm well-being. >Establish IV access >An 18-20 gauge IV catheter ensures a reliable route for
BP-140/90mmHg blood administration, reducing the risk of complications
SPO2-95% such as infiltration or hemolysis.

>Administer blood at the prescribed rate: >Infusing blood slowly (over 2-4 hours) reduces the risk of
circulatory overload and allows for monitoring of adverse
NURSING DIAGNOSIS: reactions during the transfusion.
Blood Transfusion
>Monitor vital signs during the transfusion: >Frequent monitoring of BP, HR, RR, and temperature
ensures early detection of any transfusion-related
reactions or complications, facilitating prompt intervention.

>Assess for transfusion reactions: >Close observation for fever, chills, rash, or difficulty
breathing during the transfusion ensures that any adverse
reactions are identified early, allowing for immediate
action such as stopping the transfusion
>Hemoglobin or hematocrit levels should be assessed
Follow-up lab tests:
within 2-3 days to evaluate the effectiveness of the
transfusion and monitor for any improvement in blood
Edx:
volume and oxygen-carrying capacity.
>Inform about potential reactions: >Teach the patient to report any signs of transfusion
reactions such as fever, chills, rash, shortness of breath,
>Educate the patient to report any signs of transfusion reactions chest pain, or back pain immediately.
such as fever, chills, rash, shortness of breath, chest pain, or
back pain immediately. >Early detection of transfusion reactions allows for prompt
medical intervention, minimizing risk to the patient.
Post-transfusion monitoring:
>Fluid overload is a potential complication after blood
>Advise the patient to monitor for signs of fluid overload such as transfusion, and recognizing early signs can help prevent
swelling, shortness of breath, or increased blood pressure, and serious outcomes such as pulmonary edema.
to seek medical help if any of these symptoms occur.
>Rest and a balanced diet will aid in recovery, allowing the
>Encourage the patient to rest and gradually increase their body to regenerate blood cells and restore normal
activity level as their energy improves. Recommend a balanced function.
diet rich in iron to support red blood cell production.
>Follow-up appointments ensure that any complications
>Remind the patient about follow-up appointments and are detected early, and the success of the transfusion can be
laboratory tests to monitor hemoglobin levels and overall assessed.
recovery.
 Easter College
DEPARTMENT OF NURSING

Patient/age/sex: _______________________________________________ Diagnosis:________________________________________________________ Ward: _________________________________

DATA GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

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Easter College
DEPARTMENT OF NURSING

Patient/age/sex: _______________________________________________ Diagnosis:________________________________________________________ Ward: _________________________________

DATA GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

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Easter College
DEPARTMENT OF NURSING

Patient/age/sex: _______________________________________________ Diagnosis:________________________________________________________ Ward: _________________________________

DATA GOALS NURSING INTERVENTIONS RATIONALE EVALUATION

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