EXPLANATION OF

ASSESSMENT OUTCOMES INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM
Subjective: Ineffective breathing STO: Within 30 Dx:Assess and record The average rate of STO: (Goal Met)
pattern is considered minutes – 1 hour of respiratory rate and respiration for adults is
 “nahihirapan the state in which the effective nursing depth at least every 4 10 to 20 breaths per Within 30 minutes – 1
huminga ang rate, depth, timing, and interventions, the hours. minute. It is important hour of effective
anak ko” as rhythm, or the pattern patient’s will be able to take action when nursing interventions,
verbalized by of breathing is altered. to maintains an there is an alteration inthe patient was able to
the mother. When the abdominal effective breathing the pattern of breathing maintain an effective
wall excursion during pattern, as evidenced to detect early signs of breathing pattern, as
Objective: inspiration, expiration, by relaxed breathing at respiratory compromise. evidenced by relaxed
or both do not maintain normal rate and depth breathing at normal
 Use of optimum ventilation and absence of Work of breathing rate and depth and
accessory for the individual. The dyspnea. increases greatly as lung absence of dyspnea.
muscle. body is most likely not Assess for use of compliance decreases.
 Restlessness getting enough oxygen accessory muscle.
 Labored to the cells. Respiratory These signs signify an
breathing failure may be increase in respiratory
correlated with effort. LTO: (Goal Met)
 Vital signs:
Temp: 37.8 variations in Observe for retractions
LTO: Within 24 – 48 Within 24 – 48 hours
respiratory rate, or flaring of nostrils. Malnutrition may result
PR: 140bpm hours of effective of effective nursing
abdominal, and in premature
RR: 69cpm nursing interventions, interventions, the
thoracic pattern. Evaluate nutritional development of
O2 Sat: 90 the patient will patient verbalized
status (e.g., weight, respiratory failure
verbalize feeling feeling comfortable
comfortable when
albumin level, because it reduces
Source: electrolyte level). respiratory mass and when breathing.
breathing.
https://nurseslabs.com/i strength.
neffective-breathing-
pattern/ A sitting position
Tx: Place patient with permits maximum lung
proper body alignment excursion and chest
Nursing Diagnosis for maximum expansion.
 breathing pattern.
 Ineffective
Breathing Provide respiratory Beta-adrenergic agonist
related to medications and medications relax
pediatric oxygen, per doctor’s airway smooth muscles
community order. and cause
acquired bronchodilation to open
pneumonia as air passages.
manifested by
alterations in Edx: Educate patient This information
depth of and guardians about promotes safe and
breathing. medications: effective medication
indications, dosage, administration.
frequency, and
possible side effects.
Incorporate review of
metered-dose inhaler
and nebulizer
treatments, as needed.

Educate patient or
significant other
proper breathing,
coughing, and
splinting methods. These allow sufficient
mobilization of
Teach patient about secretions.
pursed-lip breathing,
abdominal breathing,
performing relaxation These measures allow
techniques, taking patient to participate in
prescribed medications maintaining health
(ensuring accuracy of status and improve
dose and frequency ventilation.
and monitoring
adverse effects), and
scheduling activities to
avoid fatigue and
provide for rest
periods.