NURSING CARE PLAN PLANNING GOALS OF INTERVENTION CARE RATIONALE >At the end of nursing interventions, patient will

be able to: 1. Report feeling comfortab le when breathing. 2. Report feeling rested each visit.

CUES

NURSING DIAGNOSIS

W/ IMPLEMENTATION

EVALUATION

S: >Ineffective Hindi siya Breathing pattern mkahinga ng R/T Shortness of normal. breath, bronchoconstricti O: on. >Restlessness >weaklooking >Crackles sound >Shallow breathing >RR=50 breath/min

1. Assess and record RR and depth at least every hour. R : To detect early signs of respiratory compromise. 2. Assist patient to comfortable position, such as supporting upper extremities with pillows. R : These measures promote comfort and chest expansion. 3. Schedule necessary activities to provide periods of rest.

1. Monitored and recorded the RR and depth at least every hour.

1. Patient verbalized feeling comfortable when breathing.

2. Supported patient to comfortable position such as high fowlers position.

2. Each visit, patient reports that she feels rested.

3. Restore normal breathing pattern as manifeste d by absence of dyspnea

3. Encouraged light activities such as (walking, doing basic household chores.)

3. When patient carries out activities of daily living, breathing pattern remains normal, RR is 20 breath/min.

and normal RR. 4. Demonstr ate appropriat e coping behaviors.

R : Prevents fatigue and reduces Oxygen demands. 4. Note emotional responses; crying and grasping. R : Hyperventilation may be a factor. 4. Observed emotional responses like crying and grasping. 4. Patient showed appropriate behaviour and cooperative.

REFERENCE: Nursing Diagnosis Reference Manual 2nd Edition

5. Stressed the importance of taking medications religiously.

5. Medications, as prescribed were taken by the patient.