NURSING CARE PLAN (CTT)
ASSESSMENT
Subjective: “Nahihirapan pa
din ako huminga na parang
lalo ko nararamdaman yung
sakit dito sa pinagpasukan/
sa pinaghugutan sa bandang
dibdib ko” as verbalized by
the patient.
Objective: Pain scale 7/10
Stated 2 - 3 words before he
stops and has to breathe
again.
T = 36.2 ⁰C
P = 78 BPM
R = 25 / 27
BP = 130 / 90 mmHg
DIAGNOSIS
Ineffective breathing
pattern r/t pain as
evidenced by changes in
respiratory rate, depth and
pattern from baseline
tachypnea and change in
depth respiration.
PLANNING
After 8 hrs of nursing
intervention, the respiratory
rate of the patient will be 12
- 20 BPM. Demonstrate an
effective RR depth and
pattern and will be able to
communicate well.
INTERVENTION
Independent: Established
rapport
Obtain V/S
Placed patient in semi
fowler position
Encourage slower / deeper
respiration, use of pursed lip
technique and so on..
Maintain calm attitude and
pleasing approach while
RATIONALE
To gain patient’s
cooperation and reduce
anxiety.
Help determine patient’s
current Health status and
verbalize efficacy of nursing
interventions rendered.
Provide physiological and
psychological ease in
inspiration.
To assist client in in taking
control of the situation
To limit anxiety
EVALUATION
After 8 hours of of nursing
intervention goals are
partially met.
R = 20BPM
Tachypnea is resolved but
pain scale decreased 5 / 10
and shows ease in breathing
and communicating.
dealing with client.

Dependent: Relief pain and anti infective

Administer due medication