Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective airway After 8 hours of 1. Assess and 1. Tachypnea is After 8 hours of
clearance related to nursing intervention monitor usually present to nursing intervention
“I have been bronchospasm as the client will respirations some degree and the client was able to
extremely short of evidenced by demonstrate and breath may be pronounced demonstrate
breath for the past shortness of breath behaviors to improve sounds, noting on admission or behaviors to improve
12 hours.” airway clearance. rate and during stress or airway clearance.
sounds concurrent acute
(tachypnea, infectious process.
Objective: stridor, Respirations may be
crackles, shallow and rapid,
-Use of accessory
wheezes). with prolonged
muscle
Note expiration in
-Restlessness inspiratory comparison to
and expiratory inspiration.
-Diminished lung ratio.
sound upon
auscultation 2. Note presence 2. Respiratory
and degree of dysfunction is
-Nasal flaring
dyspnea as for variable depending
-Dyspnea reports of “air on the underlying
hunger,” process such as
-Fast and irregular restlessness, infection, allergic
breathing upon anxiety, reaction, and the
exertion respiratory stage of chronicity in
distress, use a patient with
Vital Signs
of accessory
BP: 150/86 muscles. Use established COPD
0–10 scale or
PR: 36 cpm American
HR: 112 bpm Thoracic
Society’s
02Sat: 85% “Grade of
Breathlessnes
ABG RESULT: 3. Identify the
s Scale” to
occurrence of an
PCO2 60, rate breathing
infectious process
difficulty.
pH 7.25,

PO2 50, 4. Establishes a

3. Observe sign
02 Sat 85% baseline for
and symptoms
monitoring
of infections
progression or
regression of disease
process
4. Monitor and complications.
graph serial
ABGs, pulse -Gain or maintain an
oximetry, open airway.
chest x-ray.

-Position head midline

with flexion on
appropriate for
age/condition.

5. Assist patient 5.Elevation

of the head
to assume
position of of the bed
facilitates
comfort e.g.,
elevate head respiratory
function by
of bed,
encourage use of
gravity.
patient to lean
on overbed
table or sit on
the edge of
6.Provides
the bed.
6. Encourage or patient with
some means
assist with
pursed lips to cope or
control
breathing
exercises. dyspnea and
reduce air
7. Administer
medication as trapping.
prescribed by
the physician. 7.A variety of
medication
may be used
to improve
respiration.