Name of Patient: __________ROBERTO DUTWENTY ________ Date of Admission: ___________________ Room: __________

Age: ____60_____ Sex: ___M____ Civil Status: _______ Chief Complaint: _____Shortness of breath_________________
Religion: ____________________ Attending Physician: __________________________________

PROBLEM SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

CRITERIA INTERVENTIONS

Ineffective breathing The excess secretions SHORT TERM 1.Instruct patient to 1.Increased mucus and After 8 hours of nursing
pattern r/t retained that are cleared from the After 8hours of nursing increase oral fluid intake sputum secretions can intervention the client
secretion secondary to airways by coughing or intervention, patient will to 8 glasses lead to dehydration; will:
COPD huffing are known as be able to verbalize 2.Instruct patient to do increased water intake SHORT TERM Client shall
sputum, the production understanding and deep breathing exercise can help dissolve verbalize understanding
of which is always demonstrate proper after demonstrating secretions and demonstrate proper
subjective:
abnormal. Sputum deep breathing proper technique 2.Deep breathing deep breathing
retention occurs when technique to facilitate 3.Keep environment exercise increases technique to facilitate
patients are unable to proper oxygenation to allergen free (dust, oxygen intake and can proper oxygenation to
objective: clear secretions from alleviate feather pillows, smoke, help alleviate dyspnea alleviate
their respiratory tract by hyperventilation pollen). 3.Presence may trigger hyperventilation
-Increase in respiratory themselves or with LONG TERM 4.Suction naso, allergic response that LONGTERM
rate of 29 cpm assistance After 2-3 days of nursing tracheal/oral PRN may cause further Patient shall be free of
-Shortness of breath intervention, patient will 5.Educate proper hand increase in mucus cyanosis and establish
(orthopnea) be free of cyanosis and washing secretion normal breathing
-Dyspnea establish normal 6.Position the patient in 4. These may pattern
-Nasal flaring breathing pattern semi fowler’s position compromise airway. A
- Use of accessory muscles
distended abdomen can Goal Met
in breathing
7.Review client’s chest x- interfere with normal
ray for severity of acute/ diaphragm expansion
chronic conditions 5.To increase feeling of
comfort
 6.To enable the body to
recuperate and repair
7.To prevent allergic
reactions that can cause
respiratory distress

REFERENCES:
____________________________________