NURSING CARE PLAN

Name of Patient: Helena Flordeliza Age: 81 y/o Date of Admission: 02-06-2012 Civil Status: Widowed Nationality:Filipino Occupation: Sex: Female

Chief Complaint/ Diagnosis: Difficulty of breathing

CUES

NURSING DIAGNOSIS

ANAYSIS

NURSING OBJECTIVE

NURSING INTERVENTION

SCIENTIFIC EXPLANATION

EVALUATION

Subjective: Sumasakit ang dibdib ko kapag humihinga as verbalized by the patient. Objective: Dyspnea Nasal flaring Distended neck vein Wheezing Chest pain Rapid and shallow breathing V/S taken as follows: RR: 32 breaths/min PR: 80

Difficulty of breathing related to presence of phlegm and always coughing.

Among the most common symptoms of lung disorders are cough, dyspnea, and wheezing. Less commonly, a blockage in the airways between the mouth and lungs results in a gasping sound when breathing. Problems in the lungs can also lead to coughing up of blood or hemoptysis, a bluish discoloration of the skin due to a lack of oxygen in the blood, or chest pain.

After 2 days of nursing interventions, the patients respiration shall have improved and difficulty of breathing shall have been relieved.

monitored respiratory patterns including rate, depth, and effort Auscultated breath sounds noting decreased or absent sounds, crackles, or wheezing. positioned the client to optimize respiration

With secretion in the airway, the respiration rate will increase . These abnormal lung sounds can indicate pathology associated with an altered breathing pattern. An upright position allows maximal lung expansion while lying flat on bed causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breath. This technique can help increase sputum clearance and decrease cough spasm. Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia.

After 2 days of nursing intervention, the patient respiration has been improved and difficulty of breathing has been relieved as evidenced by: (-) dyspnea (-) nasal flaring (-) distended neck vein (-) wheezing RR: 25 breaths/min Nursing objective was met.

encouraged patient to perform deep breathing encouraged ambulation as tolerated without causing exhaustion scheduled rest periods before and after activity.

ensured adequate hydration within cardiac and renal reserves

Respiratory clients with dyspnea are easily exhausted and need additional rest. The elderly are prone to dehydration and hydration helps decrease the viscosity

of secretions, facilitating expectoration. assisted the client to identify other factors that can exacerbate or precipitate ineffective breathing episode administered medication as ordered Awareness of precipitating factors helps the client avoid

them and decreases risk of ineffective breathing patterns Treatment of patients with acute and chronic bronchopulmonary diseases, rhinosinusitis, laryngopharyngitis or exacerbations of these chronic diseases in association with mucus production and transport. Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions

administer oxygen as ordered