Assessment Diagnosis Planning Intervention Rationale Evaluation

After my 8 hours of  Frequently assess  Early identification At the end of 8-

Subjective: Ineffective nursing interventions respiratory rate, pattern, of ineffective hours of Nursing
breathing pattern the patient will and breath sounds. Note respirations allows
establish an effective Interventions, th
Client refrains from related manifestations of timely initiation of
respiratory pattern goal was partial
talking because he finds decreased lung ineffective breathing. interventions.
met as evidence
it hard to breathe while expansion
a) Absence of by:
doing so.
dyspnea
upon activity  Place patient with
b) Respiratory  A sitting a. Dyspnea
Objective: proper body not
rate
alignment for position manifeste
maintained at
 With observed normal range maximum breathing permits b. R=24cpm
rapid -shallow (16-20 cpm) pattern. maximum
breathing. c) Client’s o Place in Fowler’s, lung excursion
 Difficulty of verbalization
of
High Fowler’s or and chest
breathing orthopneic (with
improvement expansion.
 RR – 38bpm in respiration. head and arms
supported on the o These
overbed table) positions
position to reduce the
facilitate work of
breathing and breathing
lung expansion. and
increases
lung
expansion,
especially
the basilar
 areas.

 Encourage sustained
deep breaths by:
o Using  These techniques
demonstration: promote deep
highlighting inspiration, which
slow inhalation, increases
holding end oxygenation and
inspiration for a prevents
few seconds, atelectasis.
and passive Controlled
exhalation breathing
o Utilizing methods may also
incentive aid slow
spirometer respirations in
o Requiring the patients who are
patient to yawn tachypneic.
Prolonged
expiration
prevents air
trapping.
 Provide
respiratory
medications and  Beta-
oxygen, per adrenergic
doctor’s orders. agonist
medications
relax airway
smooth
 muscles and
cause
bronchodilatio
n to open air
passages.

 This facilitates
 Maintain a clear adequate
airway by clearance of
encouraging patie secretions.
nt to mobilize own
secretions with
successful
coughing.

 These allow
sufficient
 Educate patient or
mobilization of
significant other
secretions.
proper breathing,
coughing, and
splinting methods.