Nursing Care Plan By: Amy

Sherman

PRIORITY NURSING EXPECTED IMPLEMENTATION/INTERVENTIONS: REASSESSMENT:

PROBLEM: OUTCOMES:
NANDA: 1. Patient’s RR will stay A: Assess and record respiratory rate and depth at 1. Patient’s RR
within 5 breaths/min least every 4 hours remains within
INEFFECTIVE of baseline (12- R: to detect early signs of respiratory compromise. established limits.
BREATHING 20bpm) (Sparks & Taylor, pg.44) 2. Patient indicates,
PATTERN 2. Patient will report A: Auscultate breath sounds at least every 4 hours either verbally or
feeling comfortable R: to detect decreased or adventitious breath through behavior,
r/t: when breathing sounds (S&T, pg. 44) feeling comfortable
3. Patient will achieve T: Assist Patient to a comfortable position, for when breathing.
respiratory muscle fatigue maximum lung example, by supporting the upper extremities with 3. Patient
(bilateral pneumonia) expansion with pillows, providing an overbed table with a pillow to demonstrates
adequate ventilation lean on and elevation the head of the bed. maximum lung
Defining (be able to raise R: These measures promote comfort, chest expansion with
Characteristics/ AEB’s Incentive Spirometer expansion, and ventilation of basilar lung fields. adequate
level above 1000 – (S&T, pg. 44) ventilation
 Abnormal current level) T: Provide rest periods between breathing
breathing pattern enhancement measures
(shallow depth R: to avoid fatigue (S&T, pg. 44)
and increased E: Teach patient how to properly use incentive
rate) spirometer, perform relaxation techniques, taking
 Dyspnea prescribed medications (ensuring accuracy of dose
 Orthopnea and frequency and monitoring adverse effects) and
 Tachypnea (RR scheduling activities to avoid fatigue and provide
26, 32) for periods of rest.
R: These measures allow patient to participate in
maintaining health status and improve ventilation.
(S&T, pg 44)

Evaluation: Achieved, Improving, Maintaining, Declining (Highlight)

Overall Plan of Care: Continue, Modify, Discontinue (Explain) – Patient will continue treatment to improve breathing by using
interventions introduced. Patient will show improvement with a RR in normal range (12-20 bpm). Patient will be discharged with at home
care plan to continue healing. ALS