St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

CUES/ NURSING BACKGROUND GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
ASSESSMENT DIAGNOSIS KNOWLEDGE RATIONALE

Subjective: Ineffective Breathing Ineffective breathing pattern is Within the 8hrs shift, the patient Goals met. The patient remai
- Patient A.C., complaints Pattern, Related to a state in which the patient's will demonstrate effective cooperative with all breath
of abdominal pain which pain, diaphragmatic inspiration and/or expiration breathing as evidenced by: exercises and incentive spirom
may inhibit deep dysfunction, or does not provide adequate during the 7AM–3PM shift.
ventilation. Abdominal trauma saturation remained at or ab
breathing. respiratory  RR within 12–20 cpm
may cause pain and 98%, lung sounds were clear,
compromise diaphragmatic splinting,
 Normal O2 saturation ≥ no signs of respiratory distress w
Objective: secondary to inhibiting full expansion of the 95% on room air observed. Pain was effectiv
- Oxygen saturation at abdominal trauma. lungs and promoting shallow  Proper use of incentive managed with medications and n
98%, but at risk for breathing, which may result in spirometer every 2 hours pharmacologic strategies. Pat
ineffective breathing due hypoxia, atelectasis, or  Absence of respiratory verbalized understanding of
to abdominal trauma. respiratory distress. Nurses distress (no nasal flaring, purpose of exercises
play a vital role in promoting accessory muscle use) demonstrated correct technique.
- Physician ordered optimal ventilation through patient actively participated in
incentive spirometry positioning, breathing educational sessions, verbal
during waking hours exercises, and timely understanding of the purpose of
medication administration. interventions, and demonstr
A1. To improve the patient’s A1. Positioned the patient in semi-Fowler’s
proper use of the incen
- Physician ordered deep breathing pattern within the shift position. Elevating the head of the bed spirometer and breath
breathing and coughing by encouraging the use of promotes optimal lung expansion and techniques. Compliance w
exercises incentive spirometry every 2 reduces pressure on the diaphragm. exercises improved, and pat
hours, assisting in deep breathing expressed confidence in continu
- Physician ordered and coughing exercises every 2 these practices.
bronchodilator therapy hours, and maintaining O2
(Salbutamol + Ipratropium saturation ≥95%, thereby
q8) promoting effective lung
- Potential for impaired ventilation and reducing the risk
lung expansion due to of complications such as
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

pain and trauma atelectasis.

B. To ensure optimal lung B1. Reminded and assisted the patient in

expansion by assisting the patient using the incentive spirometer every 2
to perform incentive spirometry hours during waking hours. Consistent use
at least 4 times during the shift, of the device improves alveolar inflation
and to prevent respiratory and prevents lung collapse (atelectasis).
complications such as atelectasis.
B2. Set short-term performance goals (e.g.,
10 sustained inhalations per use) and
encouraged the patient to meet them.
Setting achievable goals motivates patient
compliance and tracks progress.

B3. Monitored lung sounds before and

after spirometry [Link] assess
effectiveness of lung expansion techniques
and detect early signs of congestion or
reduced breath sounds.

C. To reduce the risk of retained [Link] the patient how to splint the
pulmonary secretions by abdomen with a pillow while coughing.
encouraging deep breathing and Supports the abdominal wall, reduces
coughing exercises every 2 pain, and facilitates effective coughing.
hours, and promoting airway
clearance. C2. Supervised deep breathing and
coughing exercises every 2 hours.
Promotes mobilization of secretions and
reduces the risk of pneumonia.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

C3. Provided adequate hydration as

tolerated. Maintains moist mucous
membranes and helps in thinning
respiratory secretions.

D. To maintain normal D1. Continuously monitored SpO₂ using

respiratory function by keeping pulse oximetry. Immediate detection of
the oxygen saturation above 95% hypoxia allows timely intervention.
throughout the shift.
D2. Encouraged the patient to take slow,
deep breaths when SpO₂ decreased below
baseline. Promotes alveolar gas exchange
and improves oxygenation.

D3. Collaborated with the physician for

possible oxygen therapy if oxygen
saturation dropped below 92%. Ensures
that respiratory support is initiated
promptly if required.

E. To manage pain effectively E1. Administered IV Paracetamol and

during the shift to allow better Tramadol as prescribed and assessed pain
participation in respiratory scale before and after. Adequate pain
exercises. control reduces diaphragmatic splinting
and improves ventilation.
E2. Used non-pharmacologic pain relief
such as guided breathing, distraction, and
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

position changes. Adjunct techniques

enhance comfort and reduce reliance on
analgesics alone.

E3. Monitored for side effects of

analgesics (e.g., respiratory depression or
sedation). Ensures safety and supports
decision-making about continuing or
adjusting medication.

F. To educate the patient on the F1. Provided simple explanation of how

importance of breathing incentive spirometry and breathing
exercises and compliance with exercises prevent [Link]
prescribed respiratory treatments understanding, which encourages
during the shift. cooperation.

F2. Involved the patient in setting

reminders for each spirometry use (e.g.,
using bedside clock). Promotes
independence and accountability in self-
care.

F3. Encouraged the patient to ask questions

about respiratory care and medications.
Reduces anxiety and builds trust with the
healthcare team.\

G. To promote the patient’s G1. Educated the patient on the purpose of

understanding and active incentive spirometry and how it helps prevent
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

participation in respiratory care by lung complications like atelectasis and

providing at least 3 educational pneumonia. Informed patients are more likely
interactions during the shift, thereby to comply when they understand the "why"
improving compliance with behind the procedure.
treatment and exercises.
G2. Encouraged the patient by affirming
progress after each use of the spirometer and
breath sounds assessment, using positive
reinforcement. Verbal encouragement boosts
motivation, reduces anxiety, and increases
cooperation.

G3. Explained the importance of deep

breathing and coughing exercises, including
abdominal splinting with a pillow to reduce
pain during coughing. Teaching proper
technique ensures safety and effectiveness of
exercises, and promotes independence.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

CUES/ NURSING BACKGROUND GOALS AND OBJECTIVES NURSING INTERVENTIONS AND EVALUATION
ASSESSMENT DIAGNOSIS KNOWLEDGE RATIONALE

Subjective: (-) Electrolyte Imbalance Electrolyte imbalance, GOAL: Within the 8hrs shift, the Goals met. The patient remai
(Hypokalemia) specifically hypokalemia, patient’s potassium level will trend hemodynamically stable during
Objective: Related to Trauma- refers to a serum potassium toward the normal range (≥3.5 7AM–3PM shift. HR trended do
induced fluid shifts and level below 3.5 mmol/L, which mmol/L) or show clinical to <110 bpm, ECG remained wi
- Heart rate of 113 bpm ongoing KCl can disrupt cellular functions, improvement, as evidenced by: normal limits, and no signs
(Tachycardia) replacement therapy particularly in the heart and worsening hypokalemia (mu
muscles. In trauma patients,  Decreased heart rate weakness, cramps, etc.) were no
- Potassium level of 2.96 fluid shifts, bleeding, and (approaching normal range) IV site remained patent and
mmol/L (Low potassium – stress responses can contribute  Absence of muscle weakness from complications. Pat
normal: 3.5–5.0 mmol/L) to potassium loss. or cramps verbalized understanding
Additionally, this patient is  No ECG signs of hypokalemia potassium therapy and activ
- Ongoing IV Potassium currently receiving IV (if results are made available) participated in care.
Chloride (KCl) infusion in Potassium Chloride (KCl)  Completion of prescribed IV
PNSS replacement, which indicates KCl dose without adverse
an ongoing correction of reaction
- Muscle weakness or hypokalemia. If uncorrected,
reduced motor strength hypokalemia can lead to A. To maintain optimal potassium
arrhythmias, muscle weakness, levels by closely monitoring vital A1. Monitored heart rate and blood pressure
- Vital signs closely fatigue, and impaired cardiac signs, cardiac rhythm, and every 2–4 hours during the shift. Tachycardia
monitored due to electrolyte conduction. Continuous laboratory results, and to prevent and hypotension may indicate worsening
imbalance monitoring of vital signs, ECG complications such as arrhythmia hypokalemia or early arrhythmias.
changes, serum potassium
- At risk for cardiac levels, and IV infusion rate is
arrhythmias and essential in preventing
neuromuscular dysfunction complications. A2. Reviewed and documented potassium
levels from latest labs and monitored for trends.
Continuous monitoring ensures that IV
replacement is adequate and safe.

A3. Observed ECG monitor for any signs of

 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

hypokalemia (e.g., flattened T waves, U waves,

ST depression). Early ECG changes can signal
impending arrhythmias, allowing for timely
intervention.

B. To ensure safe administration of B1. Assessed IV site hourly for signs of

potassium chloride infusion without phlebitis or infiltration (e.g., redness, swelling,
complications by performing regular warmth, or pain). KCl is irritating to veins and
IV site assessment and monitoring can cause tissue damage if extravasated.
infusion rate during the shift.
B2. Verified correct infusion rate and pump
setting based on physician’s [Link] rapid
infusion which can lead to cardiac arrest or
hyperkalemia.

B3. Collaborated with the healthcare team

regarding ongoing potassium replacement
based on lab values and clinical presentation.
Supports individualized care planning and
medication adjustment.

C. To prevent complications related C1. Assessed for muscle weakness, cramps, or

to hypokalemia (e.g., muscle fatigue every 4 hours. These are clinical signs
weakness, arrhythmias) by assessing of worsening hypokalemia.
for neuromuscular changes and
ensuring patient safety throughout C2. Maintained a safe environment (e.g., bed in
the shift. lowest position, side rails up) to prevent injury
in case of dizziness or weakness. Fall
prevention is essential, especially in electrolyte
imbalances.

C3. Educated the patient to report any unusual

 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING and ALLIED HEALTH SCIENCES
NURSING PROGRAM
Center of Excellence for Nursing
PAASCU LEVEL IV Accredited
1st Semester | AY 2023-2024

sensations such as palpitations, chest tightness,

or tingling. Early reporting enables prompt
intervention for potentially serious
complications.

D. To educate and encourage the D1. Explained in simple terms the importance
patient to understand the importance of potassium in heart and muscle function.
of potassium balance and treatment Promotes patient understanding and
compliance during the shift. cooperation.

D2. Encouraged patient to ask questions about

his IV therapy and ongoing labs. Engaging the
patient in care increases awareness and
participation.

D3. Provided reassurance and updates about

potassium levels and progress during the shift.
Reduces anxiety and fosters trust in the care
team.