Scenario 1

Assessment data Nursing diagnosis Plan / Expected Implementation / Nursing Rational Evaluation
outcome intervention
Subjective: Ineffective After 30 minutes of  Assess rate and to detect early signs Establish a
pt. said " I have Breathing Pattern nursing of respiratory normal/effective
depth of respirations, compromise.
difficulty in related to hypoxia intervention, the respiratory patter
breathing manifested by patient will be able type of n
changes in depth to do coping
breathing pattern
Objective: and rhythm mechanisms to
O2 saturation of improve his
85%, and abnormal breathing pattern
ABGS

 Auscultate breath to detect decreased or

sounds at least every adventitious breath
sounds, report
4 hours changes.

 Utilize pulse Pulse oximetry is a

oximetry to check helpful tool to detect
alterations in
oxygen saturation oxygenation
and pulse rate. initially. 
 helps reduce
 Administer O2 to the hypoxemia and
patient. relieve respiratory
distress.

 Elevated head of For chest expansion

bed.

 assist client to These techniques

promote deep
learn breathing inspiration, which
exercises. increases
oxygenation and
prevents atelectasis.
Controlled breathing
methods may also aid
slow respirations in
patients who are
tachypneic.
Prolonged expiration
prevents air trapping.

to conserve energy
 Help patient with and avoid
ADLs, as needed overexertion and
fatigue.
Subjective: Ineffective airway During the client’s  Assess the rate, Tachypnea, shallow At the end of the
pt. said " I have clearance related to stay at the hospital, rhythm, and depth of respirations and
shift, the patient
difficulty in productive cough he will be able to respiration, chest asymmetric chest
breathing and cough manifested by maintain patent movement, and use movement are was able to
changes in depth airway of accessory frequently present
display patency of
Objective: and rhythm of muscles. because of
 On respiration, discomfort of moving airway as
auscultation, tachycardia, sputum chest wall and/or
manifested by:
noted a and hypoxia fluid in lung due to a
wheeze compensatory .
sounds in response to airway
Client’s
both side of obstruction.
chest. respiratory rate is
 Productive
within normal
cough with  Assess cough Coughing is the most
greenish effectiveness and effective way to
secretion. productivity remove secretions. 
 Pt. is
tachycardia
with irregular  Auscultate lung
respiration fields, noting areas Decreased airflow
of decreased or occurs in areas with
absent airflow and consolidated fluid. 
adventitious breath
sounds: crackles,
wheezes.
 Observe the sputum Changes in sputum
color, viscosity, and characteristics may
odor. Report indicate infection
changes.

 Suction as indicated Stimulates cough or

mechanically clears
airway in patient who
is unable to do so
because of ineffective
cough or decreased
level of
consciousness.