Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective After hr of nursing Independent:

Objective: breathing pattern intervention the
• Tachypnea related to broncho patient indicates, • Place patient • A sitting position
constriction as either verbally or with proper body permits maximum
• Use of
evidenced by through behavior, alignment (semi- lung excursion
accessory used of accessory feeling fowler position) for and chest
muscles in muscle, nasal comfortable when maximum expansion.
breathing flaring, tachypnea, breathing. breathing pattern.
O2: 91%
• O2: 91% • Suction
• Nasal flaring secretions, as • This is to clear
• necessary. blockage in
airway.
• Stay with the
patient during • This will reduce
acute episodes of the patient’s
respiratory anxiety, thereby
distress. reducing oxygen
demand.

• Monitored vital • to obtain

Signs baseline data

• Assess for • Respiratory rate

discomfort and rhythm
changes are early
warning signs of
impending
respiratory
difficulties.
Dependent:

• Administered O2 • Oxygen therapy

regulated at 2 lpm is tx that increase
via nasal cannula the amount of
as ordered and oxygen your lungs
administered received and
prescribed deliver to the
respiratory blood.
medication

Collaborative:

• Consult dietitian • COPD may

for dietary cause malnutrition
modifications. which can affect
breathing pattern.
Good nutrition can
strengthen the
functionality of
respiratory
muscles.

• Provide • Beta-adrenergic
respiratory agonist
medications and medications relax
oxygen, per airway smooth
doctor’s orders. muscles and
cause
bronchodilation to
open air
passages.