NURSING CARE PLAN

Nursing Problem
Cues

Analysis

Goal/Objectives

Nursing
Interventions

Rationale

Evaluatio
n

Nursing Diagnosis:

Ineffective
Breathing Pattern is
defined as
inspiration and/or
expiration that do
not provide
adequate
ventilation.

Goal:
After 8 hours of
nursing
intervention, the
client will be able to:

a) Monitor vital
signs

a) These signs,
which should be
looked at in
total, are
checked to
monitor
functions of the
body. The signs
reflect changes
in function that
otherwise might
not be
observed.

The client
was able
reestablish

Ineffective Breathing
Pattern secondary to
community acquired
pneumonia as
manifested by
alterations in depth
of breathing.
Subjective:
Nahihirapan
huminga yung baby
ko, may halak daw
kasi siya. Verbalized
by the clients
mother.
Objective:
-

Use of
accessory
muscles
Labored
breathing

A dyspneic person
often appears
anxious and may
experience
shortness of
breath, a feeling of
being unable to get
enough air.
Dyspnea have
many causes, most
of which stem from
cardiac and
respiratory
disorders. It is a

Reestablish
and maintain
effective
respiratory
pattern via
oxygen
administration
thru nasal
cannula
without the use
of accessory
muscles and
other signs of
hypoxia

Objectives:
After 2 hours of
nursing
intervention, the

b) Assess
respiratory rate,
rhythm and
depth

c) Assess for
pain/discomfort
d) Administer O2
regulated at 2
lpm via nasal
cannula as
ordered and
administer

b) Respiratory
rate and rhythm
changes are
early warning
signs of
impending
respiratory
difficulties
c) That may
restrict

and
maintain
effective
respiratory
pattern via
oxygen
administrati
on thru
nasal
cannula
without the
use the use
of
accessory
muscles
and other
signs of
hypoxia

Restlessness

Measurement:
T: 36C
RR: 68 cpm
PR: 125 bpm

subjective feeling
as it cannot be
directly observed
but is reported by
the client. (Kozier,
Vol. 2, 7th Ed., p.
1346)

client will be able to:

Maintain
normal vital
signs

prescribed
respiratory
medications

respiratory
effort
d) For
management of
underlying
pulmonary
condition and
respiratory
distress