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West Visayas State University

College of Nursing

Name of Patient: Attending Physician:

Age: Ward/Bed Number: Impression/Diagnosis:

Nursing Rationale (Scientific

Clustered Cues Objectives of Care/ Nursing Interventions Rationale Evaluation
Diagnosis Basis)
Outcome Criteria (Scientific Basis)
08/ 26 /17 Ineffective Ineffective breathing After 2 hours of nursing 1.Monitor and record vital To obtain baseline
9:00am Breathing Pattern pattern occurs when interventions,the signs. data. 11:00 am
r/t decreased lung inspiration and expiration patient will be able to:
volume capacity does not provide adequate 1. Demonstrate 2.Assess breath sounds To note for respiratory
Orthopnea ventilation.Pleural appropriate ,respiratory depth and abnormalities that
Use of inflammation causes sharp coping behaviors rhythm. may indicate early
accessory localized pain that increases and methods to respiratory
muscles deep pf breathing,coughing improve compromise and
Diaphoresis and movement.This can breathing hypoxia.
Presence result to shallow and rapid pattern.
of crackles breathing pattern.Distal 2. Apply techniques 3.Elevate head of bed. To promote lung
on both airways and alveoli may not that would expansion.
lung fields expand optimally with each improve
breath,increasing the breathing 4.Encourage patient to To promote lung
possibility of atelectasis and pattern and free perform deep breathing expansion.
impaired gas exchange. form signs and exercises.
symptoms of
respiratory 5.Provide relaxing To promote adequate
distress. environment. rest periods to limit

6.Administer oxygen as To maximize oxygen

ordered. available for cellular

7.Administer prescribed For the

medication as ordered. pharmacological
management of the
`patients condition.

Students Name: RLE GROUP 2

Clinical Instructor: Mrs. Ma. Teresa M. Cercado,RN