 Increase in

respiratory rate of 31 cpm Shortness of breath (orthopnea) Dyspnea Use of accessory muscles in breathing
Altered chest excursion Nasal Flaring Increased anteriorposterior diameter

OBJECTIVES SHORT TERMAfter 2-3 hours of nursing intervention, patient will be able to verbalize understanding
and demonstrate proper deep breathing technique to facilitate proper oxygenation to alleviate hyperventilation
LONG TERM After 2-3 days of nursing intervention, patient will be free of cyanosis and establish normal
breathing pattern

NURSING INTERVENTIONS 1. Establish rapport with patient 2. Instruct patient to increase oral fluid intake to 8-10
glasses 3. Instruct patient to do deep breathing exercise after demonstrating proper technique 4. Keep
environment allergen free (dust, feather pillows, smoke, pollen) 5. Take and VS 6. Suction naso, tracheal/oral PRN
7. Educate proper hand washing 8. Position the patient in semi fowler’s position 9. Encourage patient to eat
nutritious foods such as green leafy vegetables and lean meat 10. Review client’s chest x-ray for severity of
acute/ chronic conditions

RATIONALE 1. To gain patient’s trust and cooperation 2. Increased mucus and sputum secretions can lead to
dehydration; increased water intake can help dissolve secretions 3. Deep breathing exercise increases oxygen
intake and can help alleviate dyspnea 4. Presence may trigger allergic response that may cause further increase
in mucus secretion 5. To get baseline data 6. These may compromise airway. A distended abdomen can interfere
with normal diaphragm expansion 7. To increase feeling of comfort 8. To enable the body to recuperate and
repair 9. To prevent infections such as nosocomial infections 10. To prevent allergic reactions that can cause
respiratory distres
EXPECTED OUTCOMES SHORT TERMClient shall verbalize understanding and demonstrate proper deep
breathing technique to facilitate proper oxygenation to alleviate hyperventilation LONGTERM Patient shall be
free of cyanosis and establish normal breathing pattern
 With unproductive 



cough With wheezes and crackles auscultated on left lower lungfield. Presence of clear watery discharge from
her nose Restlessness Irritability

OBJECTIVES Short Term: After 3-4 hours of nursing interventions, the patient’s respiration will improve and
difficulty of breathing will be relieved.

Long Term: After 3 – 4 days of nursing interventions, the patient will maintain a patent airway.

NURSING INTERVENTIONS 1. Establish rapport to patient and SO 2. Assess patient’s condition 3. Monitor and
record V/S 4. Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds 5.
Assist patient to change position every 30 minutes 6. Elevate head of bed and align head in the middle 7. Provide
health teachings regarding effective coughing and deep breathing exercise. 8. Encourage to increase fluid intake.
9. Encourage steam inhalation 10. Administer meds as ordered

RATIONALE 1. To gain the trust and cooperation 2. To know and determine patient’s needs 3. To establish base
line data 4. To identify areas of consolidation and determine possible bronchospasm or obstruction. 5. To
mobilize secretions 6. To facilitate breathing 7. To expel the mucous 8. To liquefy secretions 9. To moisten
secretions and alleviate congestion 10. To reduce bronchospasm and mobilize secretion
EXPECTED OUTCOMES Short Term: After 3-4 hours of nursing interventions, the patient’s respiration shall have
improved and difficulty of breathing shall have been relieved.

Long Term: After 3 – 4 days of nursing interventions, the patient will have been able to maintain a patent airway.

https://www.healthline.com/health/bronchopneumonia

https://www.academia.edu/6740169/Nursing_process_and_care_plan_writing