NURSING CARE PLAN NO.

1
Ineffective breathing pattern related to Airway obstruction as evidenced by increased respiratory rate and pallor

Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective Data: Ineffective breathing pattern
“Nurse, mas nahihirapan na related to Airway obstruction as
ako huminga.” As
verbalized by the patient. respiratory rate and pallor
Objective Data:
 History of smoking
 Shortness of breath
(dyspnea)
 Pallor
 Productive cough
(yellowish)
 Poor inspiratory
effort
 Bibasilar crackles
2/3 of the way up
the posterior lung
field.
Vital signs:
 BP: 110/70mmHg
 PR: 112bpm
(tachycardic)
 RR: 30cpm
(tachypnea)
evidenced by increased
Short-term Independent:
Within 6-8 hours of
appropriate nursing
interventions:
 Patient’s respiratory
rate and pulse rate will
return within normal
range as evidenced
by no presence of skin
pallor and shortness
of breath
 Patient will show
improved breathing
pattern as evidenced
by verbalization of
feeling relaxed when
breathing.
 Patient will
demonstrate breathing
techniques to improve
breathing pattern
Dependent:
Long-term
Within 2-3 days of appropriate
nursing interventions:
 Position patient in a  Promotes lung
semi-Fowler’s to high expansion which will
Fowler’s. enable the patient to
breathe properly.
 Teach the patient  Pursed-lip breathing
breathing techniques will help allow
such as pursed lip controlled ventilation
breathing. and support airway
openings, to prevent
CO2 trapping.
 Place a pillow on the  Helps provide
patient’s head when adequate lung
sleeping
expansion while the
patient is sleeping.
 Maintain a cool, calm,  To reduce risk for
and relaxing anxiety and help the
environment. patient conserve
energy properly when
resting.
 Administer 2L of  Helps improve
oxygen via nasal breathing pattern by
cannula as ordered. relieving dyspnea
After 6 hours of appropriate
nursing interventions, the
patient:
 Patient’s
respiratory rate
and pulse rate
returned within
normal range as
evidenced by no
presence of skin
pallor and
shortness of breath
 Patient showed
improved breathing
pattern as
evidenced by
verbalization of
feeling relaxed
when breathing.
 Patient
demonstrated
breathing
techniques to
improve breathing
pattern
Vital signs:

 Patient’s respiratory  Administer  Cefuroxime helps treat  BP:120/80mmHg

rate and pulse rate will cefuroxime 750mg via bacterial infections in  PR: 90bpm
be maintained within IV as prescribed different parts of the  RR: 18cpm
 normal range as body. Long-term
evidenced by no Collaborative:
presence of skin pallor  Exercise helps patient After 3 days of appropriate
 Refer the patient for to feel better and nursing interventions:
and shortness of
evaluation of exercise condition their
breath
potential. respiratory muscles.  Patient’s
respiratory rate
 Patient will maintain and pulse rate was
improved breathing
maintained within
pattern as evidenced
by minimized normal range as
presence or no evidenced by no
presence of presence of skin
productive yellowish pallor and
cough, reduced shortness of breath
bibasilar crackles or
no crackles
 Patient improved
breathing pattern
as evidenced by
minimized
presence of
productive
yellowish cough
and reduced
bibasilar crackles.

GOAL MET.
SOAPIE CHARTING No. 1

Patient Name: Patient A.G. Date: September 28, 2022

Age: 32 years old Shift: 7:00 AM – 3:00PM
Sex: Male
Diagnosis: HIV

TIME
7:00 AM S Patient stated “Nurse, nag-iba na kulay ng kaliwang paa ko at nagsusugat itong daliri ko sa
kaliwa.”
O  History of smoking
 Shortness of breath (dyspnea)
 Pallor
 Productive cough (yellowish)
 Poor inspiratory effort
 Bibasilar crackles 2/3 of the way up the posterior lung field.

Vital signs:

 BP: 110/70mmHg
 PR: 112bpm (tachycardic)
 RR: 30cpm (tachypnea)
A Ineffective breathing pattern related to Airway obstruction as evidenced by increased
respiratory rate and pallor
P Within 6-8 hours of appropriate nursing interventions:

 Patient’s respiratory rate and pulse rate will return within normal range as evidenced
by no presence of skin pallor and shortness of breath

 Patient will show improved breathing pattern as evidenced by verbalization of feeling

relaxed when breathing.
  Patient will demonstrate breathing techniques to improve breathing pattern

8:02 AM I  Positioned patient in a semi-Fowler’s to high Fowler’s.

8:10 AM  Taught the patient breathing techniques such as pursed lip breathing.
9:30 AM  Placed a pillow on the patient’s head when sleeping
9:35 AM  Maintained a cool, calm, and relaxing environment.
10:10 AM
 Administered 2L of oxygen via nasal cannula as ordered.
11:30 AM
 Administered cefuroxime 750mg via IV as prescribed
1:15 PM
 Referred the patient for evaluation of exercise potential.
2:55 PM E After 6 hours of appropriate nursing interventions, the patient:

 Patient’s respiratory rate and pulse rate returned within normal range as evidenced
by no presence of skin pallor and shortness of breath

 Patient showed improved breathing pattern as evidenced by verbalization of feeling

relaxed when breathing.

 Patient demonstrated breathing techniques to improve breathing pattern

Vital signs:

 BP:120/80mmHg
 PR: 90bpm
 RR: 18cpm

References:

Vera M. (2022) 7 Chronic Obstructive Pulmonary Disease (COPD) Nursing Care Plans https://nurseslabs.com/chronic-obstructive-pulmonary-disease-copd-nursing-care-plans/3/

Wayne G. (2022) Ineffective Breathing Pattern Nursing Care Plan https://nurseslabs.com/ineffective-breathing-pattern/

Wagner M. (2021) Ineffective Breathing Pattern Nursing Diagnosis & Care Plan https://www.nursetogether.com/ineffective-breathing-pattern-nursing-diagnosis-care-plan/