Rogers State University

NURSING PROCESS WORKSHEET

Nursing Program

1. NURSING DIAGNOSIS: INEFFECTIVE BREATHING PATTERNS R/T RESPIRATORY

MUSCLE FATIGUE SECONDARY TO PNEUMONIA AS
MANIFESTED BY SOB, DECREASED O2 STATS, AND
WHEEZING.

2. EXPECTED OUTCOME: PT WILL REPORTS FEELING MORE COMFORTABLE WHEN

INHALING AND EXHALING.

3. INTERVENTIONS: 1. ASSESS & RECORD RESPIRATORY RATE AND DEPTH

(Five or more) AT LEAST Q4 HRS
2. AUSCULATE BREATH SOUNDS AT LEAST Q4 HRS TO
DETECT DECREASED OR ADVENTITIOUS BREATH SOUNDS
3. ENCOURAGEMENT ON INCREASING FLUIDS

4. ASSIST PT TO A COMFORTABLE UPRIGHT POSITION,

SUCH AS SUPPORT WITH EXTRA PILLOWS
5. ADMINISTER O2 AS ORDERED

4. EVALUATION OF
EXPECTED OUTCOME:
MET. PT STATED THAT SHE WAS FILLING MUCH BETTER
AND NOT “HURTING” WHEN SHE BREATHS. FACIAL OBSER-
VATIONS HAVE RETURNED TO BEING HAPPY.
Rogers State University
NURSING PROCESS WORKSHEET
Nursing Program
4. NURSING DIAGNOSIS: INEFFECTIVE AIRWAY CLEARANCE R/T EXCESSIVE
SECRETIONS RELATED SECONDARY TO PNEUMONIA AS
MANIFESTED BY SOB, DECREASED O2 STATS, AND
WHEEZING.

5. EXPECTED OUTCOME: -IMPROVED O2 STATS

-LESS SOB EPISODES
-CLEARER LUNG SOUNDS

6. INTERVENTIONS: 1. BED ELEVATED

(Five or more)
2. ENCOURAGED COUGHING

3. ENCOURAGEMENT ON INCREASING FLUIDS

4. PROVIDE O2

5. RESPIRATORY TREATMENTS

5. EVALUATION OF
EXPECTED OUTCOME:

PARTIALLY MET. O2 STATS HAVE DECRESED, LUNGS ARE

NOT ANY CLEARER, ACTUALLY THEY ARE WORSE, BUT PT
IS HAVING LESS SOB EPISODES.