NURSING CARE PLAN

Nursing Problem Cues Analysis Goal/Objectives Nursing Rationale Evaluation

Interventions

Nursing Diagnosis: Ineffective Breathing Goal: a) Monitor vital a) These signs, The client
Pattern is defined as After 8 hours of nursing signs which should be was able
Ineffective Breathing intervention, the client looked at in total, reestablish
inspiration and/or and
Pattern secondary to will be able to: are checked to
community acquired expiration that do not monitor functions of maintain
pneumonia as manifested provide adequate  Reestablish the body. The signs effective
by alterations in depth of and maintain reflect changes in respiratory
ventilation.
effective pattern via
breathing. function that
respiratory oxygen
otherwise might not administrati
A dyspneic person often pattern via
Subjective: be observed. on thru
appears anxious and oxygen
“Nahihirapan huminga b) Assess respiratory nasal
administration
yung baby ko, may halak may experience rate, rhythm and b) Respiratory rate cannula
thru nasal
daw kasi siya.” Verbalized shortness of breath, a cannula depth and rhythm changes without the
by the client’s mother. feeling of being unable without the use are early warning use the use
of accessory signs of impending of accessory
to get enough air. muscles
Objective: muscles and c) Assess for respiratory
Dyspnea have many other signs of and other
pain/discomfort difficulties
causes, most of which hypoxia signs of
- Use of accessory hypoxia
muscles stem from cardiac and d) Administer O2 c) That may restrict
- Labored breathing Objectives: regulated at 2 lpm respiratory effort
respiratory disorders. It
- Restlessness After 2 hours of nursing via nasal cannula as
is a subjective feeling as intervention, the client ordered and d) For management
it cannot be directly will be able to:
Measurement: administer of underlying
observed but is reported prescribed pulmonary
T: 36°C by the client. (Kozier,  Maintain normal respiratory condition and
RR: 68 cpm Vol. 2, 7th Ed., p. 1346) vital signs medications respiratory distress
PR: 125 bpm