Jan Marinela Manalo

NURSING CARE PLAN

ASSESSMENT NURSING DX PLANNING INTERVENTION PLANNING EVALUATION
Objective: Ineffective After 8 hours of -Auscultate chest -to identity the After 8 hours of
difficulty of breathing pattern nursing of evaluate characteristic of nursing
breathing as the related to intervention the presence of breathing pattern intervention the
patient complained. respiratory muscle client will breathing pattern. patient was able to
fatigue. establish a normal establish an
Subjective: respiratory pattern -Monitor the vital -Inadequate effective
-Dyspnea as evidenced by other sign oxygenation causes respiratory pattern.
-Cough sign and symptoms increase of PR
-Head ache of hypoxia. - Monitor the rate -To identify the
-chest pain and depth type of breathing
Vital signs: respiratory pattern.
Bp: 150/100mmhg breathing pattern
Pr: 88 bpm
Rr: 32bpm -Encourage -To provide relieve
Temp: 38.2 position comfort of causative factor
Body weight: 40kg
Heigh: 157 cm -Maintain clam -To limit the level
attitude while of anxiety
- The nurse on dealing with the
duty client
administered
O2 -Medicate with -To promote
Inhalation at analgesic ordered deeper respiration
5lmp via by the physician
nasal
cannula