Ineffective Breathing Pattern | Fatigue (Medical) | Breathing

Assessment

Nursing diagnosis

Scientific Explanatio n exposure to triggers the bronchi (large airways) contract into spasm Inflammati on narrowing of the airways excessive mucus production coughing breathing difficulties

Planning

Nursing Intervention  Establish rapport to patient and SO.  Auscultate chest, noting presence/chara cter of breath sounds, presence of secretions.  Note rate and depth of respirations  Review Laboratory data.  Administer O2 indicated for underlying pulmonary condition  Elevate HOB as appropriate.  Maintain a calm attitude while dealing with client and SO.

Rationale  To gain trust and have a better NPI.  To identify etiology/ precipitati ng factors.

Evaluation

Subjective Data: “medyo nahihirapan akong huminga” Objective data:  Looks pale  Restlessn ess  Fatigue  Use accessory muscles when breathing  (+) wheezes  With productive cough  On high back rest  Profound breathing pattern  Vital

Ineffective breathing pattern related to bronchosp asm 2 BAiAE

Short term: After 3-4 hrs of effective nursing intervention the patient will established a normaleffective respiratory pattern AEB:  (-) Restlessness  (-)fatigue  (-)Use accessory muscles when breathing  With productive cough  On moderate high back rest  Regular breathing pattern  Vital signs: T-36 P-78 R-2224 BP-100/60mmHg

 To provide relief .

 To promote physiologic/ psychologic ease of maximal inspiration  To limit level of

Short term: Goal met as evidenced by:  (-) Restlessnes s  (-)fatigue  (-)Use accessory muscles when breathing  With productive cough  On moderate high back rest  Regular breathing pattern  Vital signs: T-36 P-78 R23 BP100/60mmHg Long term

signs: T-36 P-78 R28 BP100/60mmHg Long term: During the whole duration of hospitalization the patient can/will:  Verbalize awareness of causative factors.  Maintained normal/sta ble Vital signs  Experience d free from signs of hypoxia.  To assist client in taking control of the situation . Goal met as evidenced by: able to  Verbali ze awaren ess of causati ve factors.  Encourage position of comfort. .  Health teachings:  Review etiology and possible coping behaviors  Teach conscious control of RR as appropriate.  Assist and demonstrate deep breathing and coughing exercise.  Maintai ned normal /stable Vital signs  Experi enced free .  Initiate neede d lifestyl e change s  Demon strate approp riate coping behavi ors.  Initiate needed lifestyle changes  Demonstra te appropriate coping behaviors.  Recommend energy conservation techniques anxiety. Reposition every 2 hrs.  Assist client in the use of relaxation technique.

and pacing of activities.  Encouraged adequate rest periods between activities Collaborative:  Nebuliz ation as ordered  Admini ster hydroc ortison e as ordered . > To decreased secretions and allow ease from maximal inspiration .  To limit fatigue. from cyanos is and other signs of hypoxi a.

presence of secretions.  Auscultate chest.  Encourage position of comfort.  Assist client in the use of relaxation technique. Reposition every 2 hrs.  Administer O2 indicated for underlying pulmonary condition  Elevate HOB as appropriate. . noting presence/character of breath sounds.  Health teachings:  Review etiology and possible coping behaviors Evaluation Short term: Goal met as evidenced by:  (-) Restlessness  (-)fatigue  (-)Use accessory muscles when breathing  With productive cough  On moderate high back rest  Regular breathing pattern  Vital signs: T-36 P-78 R-23 BP-100/60mmHg Long term Goal met as evidenced by: able to  Verbalize awareness of causative factors.  Initiate needed lifestyle changes  Demonstrate appropriate coping .  Assist and demonstrate deep breathing and coughing exercise.  Note rate and depth of respirations  Review Laboratory data.Assessment Subjective Data: “medyo nahihirapan akong huminga” Objective data:  Looks pale  Restlessnes s  Fatigue  Use accessory muscles when breathing  (+) wheezes  With productive cough  On high back rest  Profound breathing pattern  Vital signs: T-36 P-78 R28 BP100/60mmHg Nursing diagnosis Ineffective breathing pattern related to bronchospasm 2 BAiAE Planning Short term: After 3-4 hrs of effective nursing intervention the patient will established a normal-effective respiratory pattern AEB:  (-) Restlessness  (-)fatigue  (-)Use accessory muscles when breathing  With productive cough  On moderate high back rest  Regular breathing pattern  Vital signs: T-36 P-78 R-22-24 BP-100/60mmHg Long term: During the whole duration of hospitalization the patient can/will:  Verbalize awareness of Nursing Intervention  Establish rapport to patient and SO.  Maintain a calm attitude while dealing with client and SO.

 Teach conscious control of RR as appropriate.  Recommend energy conservation techniques and pacing of activities. . Maintained normal/stable Vital signs Experienced free from cyanosis and other signs of hypoxia. Initiate needed lifestyle changes Demonstrate appropriate coping behaviors. Maintained normal/stable Vital signs Experienced free from signs of hypoxia.   behaviors.  Encouraged adequate rest periods between activities Collaborative:  Nebulization as ordered  Administer hydrocortisone as ordered.    causative factors.

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