NURSING CARE PROCESS

Cues Nursing Analysis Goals and Implementation Rationale Evaluation

Diagnosis Objective
Ineffective SCIENTIFIC Short-term Goal: Independent: Short-term Goal:
Subjective cues: breathing ANALYSIS: After 30 minutes of After 30 minutes of nursing
pattern as Ineffective nursing intervention, the 1. Note rate and depth 1. To help intervention, the client will
-The client evidenced by breathing pattern is client will be able to be of respirations and determine if the be able to be express her
verbalized that use of accessory also known as express her knowledge type of breathing respiratory status knowledge about the
she had a muscles and inspiration and/or about the nursing pattern of the client falls nursing problem, initiate
history of heart episodes of expiration that problem, initiate needed within the normal needed lifestyle changes,
failure dyspnea does not provide lifestyle changes, and range of and participate on the
adequate participate on the return respiratory rate in return demonstration
-Sometimes, ventilation demonstration activities older adult which activities in health
she experiences (Doenges et al., in health teaching. is 16-25 cpm teaching.
a hard time in 2019). (Meiner, 2019). __Met
breathing easily Meiner & Yeager Objectives: __Partially Met
(2019) asserted 2. Encourage 2. To help control __Unmet
Objective cues: that respiratory 1. After 10 minutes of slower/deeper shortness of
symptoms common nursing intervention, the respirations, use of breath, and Objectives:
- uses accessory in older adults client will be able to pursed-lip technique. provides a quick
muscle to include alterations verbalize the etiology of and easy way to 1. Was the client able to
support her in breathing respiratory distress and slow pace of verbalize the etiology of
breathing as she pattern, dyspnea, possible coping breathing, making respiratory distress and
exhibits and coughing. behaviors using their each breath more possible coping behaviors
shortness of Abnormal own words. effective using their own words after
breath breathing patterns ( American Lung 10 minutes of nursing
in the elderly may 2. After 10 minutes of Association, n.d.).  intervention?
- Dyspnea was be indicative of nursing intervention, the __Met
noted other metabolic client will be able to 3. Assist the client in 3. To help slower __Partially Met
and respiratory verbalize the importance the use of relaxation heart rate and __Unmet
RR: 14 cpm illnesses. of good posture, proper techniques. lower blood
PR: 118 bpm Complaints of diet, coping behaviors, pressure which 2. Was the client be able to
dyspnea in older effective use of contributes to verbalize the importance of
adults may be accessory muscles, ineffective good posture, proper diet,
associated with pursed-lip breathing. breathing (Mayo coping behaviors, effective
underlying Clinic, n.d.). use of accessory muscles,
respiratory or 3. After 10 minutes of pursed-lip breathing?
cardiac disease. nursing intervention, the 4. Encourage a position 4. To promote __Met
client will be able to of comfort. physiological and __Partially Met
SITUATIONAL demonstrate good psychological ease __Unmet
ANALYSIS: posture, accessory of maximal
Upon client muscles, and pursed-lip inspiration 3. Was the client able to
assessment, usage breathing. (Doenges et al., demonstrate good posture,
of respiratory 2019). accessory muscles, and
muscles, especially Long-term Goal: pursed-lip breathing?
around the neck. After 7 days of nursing 5. Encourage client to 5. To avoid __Met
Also, only 14 cycles intervention, the client avoid overeating/gas- abdominal __Partially Met
per minutes was will be able to forming foods. distention and __Unmet
noted. According to demonstrate proper impair breathing
Meiner (2019), breathing without too efforts (Doenges Long-term Goal:
muscle strength much effort, et al., 2019). After 7 days of nursing
also weakens with demonstrate proper intervention, the client will
age, and as coping behavior, and 6. Review the etiology 6. To promote be able to demonstrate
respiratory muscles display respiratory rate of respiratory distress knowledge on the proper breathing without
weaken, it becomes within the normal range. and possible coping client and too much effort,
increasingly more behaviors. caregiver demonstrate proper coping
difficult to exert regarding etiology behavior, and display
inspiratory and of respiratory respiratory rate within the
expiratory forces, distress and normal range.
resulting to older possible coping __Met
adults making use behaviors __Partially Met
of accessory (Doenges et al., __Unmet
muscles of 2019).
respiration. The
client also had a 7. Emphasize the 7. To maximize
history of heart importance of good respiratory effort
failure, which can posture and effective (Doenges et al.,
be a factor why she use of accessory 2019).
is having ineffective muscles.
breathing patterns.
8. Encourage adequate 8. To limit fatigue
References: rest periods between (Doenges et al.,
Doenges, M., activities. 2019).
Moorhouse, M., &
Murr, A. (2016).
 Nurse's Pocket
Guide: Diagnoses,
Prioritized
Interventions, and
Rationales.
F.A. Davis.

Meiner, S., &

Yeager, J. J. (2019).
Gerontologic
Nursing (6th ed.,
364-368). Elsevier.

References:

American Lung Association. Pursed Lip Breathing. https://www.lung.org/lung-health-diseases/lung-disease-lookup/copd/patient-resources-and-videos/pursed-

lip-breathing-video#:~:text=Pursed%20lip%20breathing%20helps%20control,can%20better%20control%20your%20breath.

Doenges, M., Moorhouse, M., & Murr, A. (2016). Nurse's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. F.A. Davis.

Mayo Clinic. Relaxation techniques: Try these steps to reduce stress. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-
depth/relaxation-technique/art-20045368.

Meiner, S., & Yeager, J. J. (2019). Gerontologic Nursing (6th ed., 364-368). Elsevier.