Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: “pas pas Ineffective Short term: within 8 Independent: Independent: Short term: after 8 hours of
iyanggininhawaan breathing pattern r/t hours of nursing 1.) Determine presence of 1.) That would cause breathing nursing interventions, the
Sir” as verbalized by presence of mucous interventions, the factors/physical conditions pattern impairment patient/SO was able to
the SO secretions patient/SO will be able 2.) Note the rate and depth of 2.) To determine severity and type of identify ways to promote
to identify ways to respiration, and type of breathing breathing the client is initiating effective respiratory pattern
Objectives: promote effective 3.) Inquire about precipitating and 3.) To prevent or manage future
- Presence of respiratory pattern alleviating factors episodes of breathing problems
occasional 4.) Auscultate and percuss chest 4.) To evaluate and to determine
cough and 5.) Evaluate cough and presence of characteristics of breath sounds Long term: after 2 days of
secretions Long term: within 2 secretions 5.) Indicating possible obstruction nursing interventions, the
noted days of nursing 6.) Demonstrate the chest 6.) To promote independency and to patient was able to
- Tachypnea interventions, the physiotherapy, as indication improve mucous secretion establish normal breathing
noted patient will be able to 7.) Elevate head of bed and/or have expectoration pattern as evidenced by
- Use of establish normal the client sit up in chair, as 7.) To promote physiological and increased O2 sat within
accessory breathing pattern appropriate psychological ease of maximal normal range, RR ; 25bpm
muscles when 8.) Maintain a calm attitude while inspiration
breathing dealing with the client and SO 8.) To limit level of anxiety
noted 9.) Reposition client frequently 9.) If immobility is a factor - GOAL MET
- Presence of 10.) Demonstrate slow inhalation, 10.) These techniques promotes deep
crackles sound holding end inspiration for a few inspiration, which increases
noted upon seconds, and passive exhalation oxygenation and prevents atelectasis
auscultation Health Teachings as follows: Health Teachings as follows:
- Nasal flaring 11.) Instruct the SO to assist the 11.) To open or maintain open
as observed client in elevating the head part of airway
- Unable to the bed, or modify using pillows 12.) Extra activity can worsen
mobilize 12.) Encourage frequent rest shortness of breath. Ensure the
secretions periods and teach patient to pace patient rests between activities
noted activity 13.) Moving air can decrease
- Dullness noted 13.) Instruct the SO to provide a feelings of air hunger
 upon fan in the room or a well-ventilated
percussion area
- Fingernails and 14.) Instruct the SO to avoid giving
toenails were overeating/gas-forming foods
pale in color as 15.) Educate patient or SO the
observed proper breathing, coughing, and
- Restless as splinting methods
seen 16.) Teach patient about
- RR ; 30 bpm slower/deeper respirations,
- PR ; 125 bpm pursed-lip breathing,
- O2 sat ; 92% abdominal breathing, and
performing relaxation techniques
17.) Instruct to do ROM exercises
and ambulation, within the limits
of ability
18.) Encourage patient to mobilize
own secretions with successful
coughing
19.) Instruct the SO to assist the
child in increasing fluid intake
20.) Instruct the SO to change the
clothes of the client, when
necessary
Dependent:
21.) Administer oxygen at lowest
concentration indicated and
prescribed respiratory medications
22.) Suction secretions, as
necessary
Collaborative:
23.) Consult dietician for dietary
modifications
23.) Perform Chest Physiotherapy
14.) That may cause abdominal
distension and impair breathing
efforts
15.) These allow sufficient
mobilization of secretions
16.) These measures allow patient to
participate in maintaining health
status and improve ventilation
17.) Exercise promotes conditioning
of respiratory muscles and
ambulation can further break up and
move secretions that block the
airways
18.) This facilitates adequate
clearance of secretions
19.) Hydration can help prevent
accumulation of viscous secretions
and improve secretion clearance
20.) Enhances comfort and prevents
pneumonia
Dependent:
21.) For management of underlying
pulmonary condition, and respiratory
distress
22.) This is to clear blockage in
airway
Collaborative:
23.) Good nutrition can strengthen
the functionality of respiratory
muscles
23.) To improve mucous secretion
expectoration