Assessment Nursing Planning Implementation Scientific Rationale Evaluation

Diagnosis
Ineffective After 8 hours of Independent: Discharge Outcome:
Objective: breathing nursing intervention, Assessment
 Dyspnea pattern r/to the patient will be  Assess and record  It is important to take Achieved:
 Increased decreased lung able to: respiratory rate depth action when there is an After 8 hours of nursing
work of expansion  Maintain an and respiratory effort. alteration in the pattern intervention, the patient
breathing effective of breathing to detect maintained an effective breathing
 Rapid, breathing pattern early signs of respiratory pattern as evidenced by relax
shallow  Have a compromise. breathing, absence of dyspnea
breathing respiratory rate and calm breathing had been
 Nasal flaring and ABG level  Check the patient’s  It is important to be alert observed.
 Vital Signs: within the normal Oxygen Saturation level. on changes on the
BP: range patient’s condition. Not Achieved:
Temp:  Report feeling After 8 hours of nursing
RR: rested and a  Ask if they are “short of  Sometimes anxiety can intervention, the patient can
HR: feels comfortable breath” and note any cause dyspnea, so breathe normally even without the
 O2 Sat: when breathing dyspnea. watch the patient for “air help of mechanical ventilator
hunger” which is a sign support.
that the cause of
shortness of breath is
physical.

 Note for changes in level  Restlessness, confusion,

of consciousness. and/or irritability can be
early indicators of
insufficient oxygen to the
brain.

 Evaluate skin color,  Lack of oxygen will

temperature, capillary cause blue/cyanosis
refill; observe central coloring to the lips,
versus peripheral tongue, and fingers.
cyanosis.

 Evaluate nutritional  Malnutrition may result

status (e.g., weight, in premature
albumin level, electrolyte development of
level). respiratory failure
because it reduces
respiratory mass and
strength.

Nursing Management
 Elevate the head of the  Position promotes better
bed. lung expansion.
 Suction secretions, as  To clear blockage on
necessary. airway.

Health Teaching:
 Assist patient to breathe  This increases
slowly and stay calm. oxygenation and
Encourage the client to prevents atelectasis.
sustained deep breaths
by explaining and
demonstrating a
technique on them.

Collaboration:
 Maintain on mechanical  It helps patient to
ventilator suuport, as maintain airway.
prescribed.

 Review ABGs, pulse  To identify some

oxymetry and serial x- problems that is
rays. happening to your
patient.