ASSESSMENT NURSING PLANNING INTERVENTI RATIONALE EVALUATION

DIAGNOSIS ON
Subjective Data: Ineffective STG: Independent:
It feels like I can’t Breathing pattern After 1hour of Monitor for signs Provides for early Goal met. After
get enough air related to abnormal health teaching, and symptoms of recognition and nursing
when I breathe as accumulation of patient will be able respiratory distress intervention. interventions
verbalized by the fluid in pleural to: Identify lifestyle Promote rest and To avoid over patient
patient. space as evidenced changes that may be relaxation. exertion and demonstrated
by dyspnea, nasal required in assisting worsening of normal and
flaring, orthopnea, to prevent condition. effective breathing
Objective Data: and RR of 28 bpm. ineffective breathing Promotes tolerance pattern.
-Dyspnea pattern. Encourage for activities and
Nasal flaring Participate in ambulation and helps with lung
Orthopnea treatment regimen. motility to the expansion and
RR: 28bpm patient. ventilation.
LTG:
After 48 hours of Dependent: Helps to correct
nursing intervention, Administer hypoxemia.
patient will be able supplemental
to demonstrate oxygen. Evacuates fluid as
Assist in performing well as relieve
normal and effective
thoracentesis. dyspnea and
respiratory pattern. respiratory distress.