Patient’s Initial: Patient J.B.

Age: 7 yrs old Sex: Male Chief Complaint: Dyspnea

DATE CUES NEED NURSING DIAGNOSIS OBJECTIVES OF CARE NURSING EVALUATION
INTERVENTIONS

M Subjective cues: Abraham Ineffective breathing After 8 hrs of Independent At the end of 8
Maslow’s pattern related to nursing hrs of nursing
A ● “Naa na gyud siyay a. Monitor vital
Hierarchy inflammation of lungs as intervention, the interventions,
asthma daan ma’am signs
R of Needs evidenced by reports of patient will be able goal partially met
sugod pag anak” as
dyspnea, cough, and to: R: To detect any as evidenced by:
C verbalized by the
respiratory rate of 38 changes in health
watcher
H P status
● “Mag lisod syag hinga A. Establish a A. Stable and
H b. Auscultate for
ma’am pag ubuhon Rationale: Inflammation in normal or normal
siya” as verbalized by Y the lungs can lead to improved lung sounds oxygen
12
the watcher compromised airway respiratory R: To check for any saturation
S function, impaired gas pattern as presence or character levels and
2 I exchange, and inadequate evidenced by of breath sounds report of
Objective cues: oxygenation. This absence of relief and
0 O underscores the importance hypoxia, decreased
● Productive cough of implementing dyspnea, and episodes
2 noted L c. Note rate and
interventions that optimize tachypnea of
depth of
4 ● Dyspnea noted O respiratory function, shortness
respirations
promote effective breathing of breath
● RR: 38 G
patterns, and enhance the B. Demonstrate R: To check for type of
7AM ● O2 sat: 93% I patient’s overall absence of breathing pattern
oxygenation status. adventitious B. Auscultati
● CR: 136 C
breath on of the
sounds and d. Encouraged patient’s
cough expansion and lungs still
N
facilitate easier revealed
adventitio
E breathing. us breath
sounds
E R: By promoting lung
and
D function, optimal gas
Reference: coughing
exchange and
is still
Nurse’s Pocket Guide oxygenation can be
present.
Diagnoses, Prioritized achieved, while
Interventions, and improving ventilation
th
Rationales 16 Edition and preventing
C. The
complications like
After 8 hrs of atelectasis. patient’s
nursing caregiver
intervention, the demonstr
caregiver will be ated an
e. Assisted
able to: ability to
patient to learn
perform
breathing
airway
exercises
C. Demonstrate clearance
airway R: Assisting patients in technique
clearance learning breathing s correctly
techniques exercises supports by gentle
to improve their emotional well- tapping of
breathing being, facilitates the back
pattern of recovery and and chest
the patient rehabilitation, and percussio
empowers them to n.
take an active role in
their health.

f. Encouraged
 regular rest
periods and
teach the
patient to pace
activity

R: Extra activity can

deteriorate ineffective
breathing patterns.

g. Encouraged
adequate fluid
intake

R: By promoting
adequate fluid intake,
can support respiratory
health, alleviate
symptoms, and
improve overall lung
function.

Dependent

h. Administered
Budesonide as
ordered by the
physician

R: To reduce
inflammation in the
lungs and improve
breathing patterns.

i. Administered
oxygen therapy
as ordered

R:Increase the oxygen

levels, preventing
hypoxia and
hypoxemia.

Collaborative

j. Educated the
patient’s
caregivers on
the signs and
symptoms of
respiratory
distress and
when to seek
medical for
worsening
symptom

R: to recognize
worsening symptoms
promptly, facilitating
early intervention and
improving outcomes.

k. Demonstrated/
 assisted SO in
performing
specific airway
clearance
techniques for
the patient
such as forced
expiratory
breathing or
chest
percussion

R: Thick secretions that

are difficult to cough
up may be loosened by
tapping (percussing)
and vibrating the chest.