NCP FOR INEFFECTIVE BREATHING PATTERN

NURSING GOAL & NURSING

CUES ANALYSIS RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTIONS
S: Ineffective Inspiration and GOAL: After 8 The client was able to
breathing pattern expiration that hours of duty, the establish a normal
 The mother of related to does not provide client will be able to respiratory pattern as
the patient stated, irritability, can’t adequate establish a normal evidenced by absence
“2 months siya lie down still and ventilation. respiratory pattern of cyanosis and other
nahinto simula Pneumonia as as evidenced by signs and symptoms
nung nagka- manifested by absence of cyanosis of hypoxia.
Pneumonia siya. feeling breathless, and other signs and Goal was met.
Simula nun, and nasal flaring. symptoms of
Bonamine na hypoxia.
pinaiinom ko
sakanya”. Objectives:
After 2 hours:
 “Grabe nga yung
ubo niya e. un 1. The guardian of 1. Identify the etiology or The guardian of the
parang matunog the client will be precipitating factors. 1. It may cause breathing client was able to
na ubo. Yung able to determine impairments. determine presence of
plema niya eh presence of physical physical conditions as
kulay dilaw na conditions as noted noted in related
parang may in related factors. factors.
green ng konti.” Goal was met.

 She also added

that, “Kapag 2. The guardian of 2. Evaluate cough 2. Indicate possible The guardian of the
umuubo din siya, the client will be obstruction. client was able to note
parang hindi siya able to note presence of
makahinga eh, presence of secretions.
napapansin lang secretions. Goal was met.
naming.”

O: 3. The client will be 3. Note emotional 3. It may be The client was able to
able to present response. causing/exacerbating acute present emotional
 shortness of emotional response. or chronic hyperventilation. response.
breath Goal was met.
 weakness as
evidenced by
pleading eyes
and cough with 4. The client will be 4. a. Auscultate the chest. 4. To evaluate The client was able to
 phlegm able to present his presence/character of present his current
 facial expression current normal b. Note rate and depth of breath sounds/secretions. normal breathing
indicates breathing pattern. respirations and type of pattern.
irritation breathing pattern. Goal was met.
 presence of colds
 nose has
discharge of 5. The client will be 5. Assist with/review 5. To diagnose The client was able to
clear and sticky able to have chest x- results of necessary testing. presence/severity of lung have chest x-ray.
mucous ray. disease. Goal was met.
 there is presence
of nasal flaring
6. The guardian of 6. Assess for concomitant 6. It may restrict/limit The guardian of the
M: the client will be pain/discomfort. respiratory effort. client was able to note
able to note any any signs of
Temp – 36.5oC signs of discomfort discomfort for the
CR – 124bpm for the patient. patient.
RR – 30cpm Goal was met.
Weight – 8.7kg
Height – 19inches
7. The client will be 7. Administer oxygen at 7. For management of The client was able to
able to achieve lowest concentration underlying pulmonary achieve lowest
lowest concentration indicated and prescribed conditions, respiratory concentration of
of oxygen. respiratory medications. distress or cyanosis. oxygen.
Goal was met.

8. The client will be 8. a. Suction airway. 8. To clear secretions. The client was able to
able to participate in participate in
suctioning. b. Encourage chest suctioning.
physiotherapy Goal was met.