ASSESSMENT DATA (Subjective and Objective Cues) January 8, 2013 Subjective: Indi ko ka ginhawa gid mayad as verbalized by the

patient. Objective:

NURSING DIAGNOSIS

NURSING GOAL

NURSING INTERVENTIONS

RATIONALE

EVALUATION

Ineffective Breathing Pattern Related to Decreased Lung Volume Capacity

After 8 hours of nursing Independent: interventions the patient - Establish rapport will be able to: 1) demonstrate appropriate coping behaviors and methods to improve breathing pattern. 2) apply techniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress. - Monitor and record vital signs - Assess breath sounds, respiratory rate, depth and rhythm - Elevate head of the pt. -Assist client in the use of relaxation technique -Maximize respiratory effort with good posture and effective use if accessory muscles. -Encourage adequate rest periods between activities

Tachypnea Presence of crackles on both lung fields upon auscultation use of accessory muscles RR of 28 With CTT at

Dependent: - Administer supplemental oxygen as ordered - Check drainage of CTT every 2 hours as ordered.