Clustered Cues Objectives of Care/ Nursing Interventions Rationale Evaluation Diagnosis Basis) Outcome Criteria (Scientific Basis) 08/ 26 /17 Ineffective Ineffective breathing After 2 hours of nursing 1.Monitor and record vital To obtain baseline 9:00am Breathing Pattern pattern occurs when interventions,the signs. data. 11:00 am r/t decreased lung inspiration and expiration patient will be able to: volume capacity does not provide adequate 1. Demonstrate 2.Assess breath sounds To note for respiratory Orthopnea ventilation.Pleural appropriate ,respiratory depth and abnormalities that Use of inflammation causes sharp coping behaviors rhythm. may indicate early accessory localized pain that increases and methods to respiratory muscles deep pf breathing,coughing improve compromise and Diaphoresis and movement.This can breathing hypoxia. Presence result to shallow and rapid pattern. of crackles breathing pattern.Distal 2. Apply techniques 3.Elevate head of bed. To promote lung on both airways and alveoli may not that would expansion. lung fields expand optimally with each improve breath,increasing the breathing 4.Encourage patient to To promote lung possibility of atelectasis and pattern and free perform deep breathing expansion. impaired gas exchange. form signs and exercises. symptoms of respiratory 5.Provide relaxing To promote adequate distress. environment. rest periods to limit fatigue.
6.Administer oxygen as To maximize oxygen
ordered. available for cellular uptake.
7.Administer prescribed For the
medication as ordered. pharmacological management of the `patients condition.
Students Name: RLE GROUP 2
Clinical Instructor: Mrs. Ma. Teresa M. Cercado,RN