Nursing diagnosis:

Ineffective breathing pattern related to hyperventilation as evidenced by

RR of 27 cpm with nasal flaring, alteration of O2 saturation of 94%, dyspnea as
verbalized by the patient, “kinakapos ako sa paghinga”.

Nursing Inference:
Breathing pattern is ineffective when the body is not obtaining enough oxygen
to the cells. Ineffective Breathing Pattern will be the focus if the abdominal wall
excursion during inspiration, expiration, or both does not sustain adequate ventilation
for the individual. It is defined as a state in which one's breathing rate, depth, timing,
rhythm, or pattern has changed. In addition, as we are infected with Pneumocystis
Jirovecii, our immune system responds an inflammatory reaction in the lung
parenchyma, which leads to the production of disease-fighting antibodies. During
inflammatory response, the so-called leukotrienes adhere to the smooth muscle cells
of the lungs, triggering them to tighten and induce bronchospasm. As a result,
inadequate breathing pattern occurs.

Nursing Goal:
After 7-8 hours of nursing intervention, the patient will establish a normal O2
ranging from 95 % to 100%, established limits of RR from 12 – 20 cpm without nasal
flaring, maintains effective breathing pattern and no signs of dyspnea with the
verbalization, “hindi na ako nahihirapan huminga”.

Nursing Interventions:

INTERVENTIONS
1. Place patient with proper body
alignment (High Fowler’s) for
maximum breathing pattern.
2. Encourage diaphragmatic breathing
for patients with chronic disease.
3. Avoid high concentration of oxygen
in patients with COPD.
6. Help patient with ADLs, as
RATIONALE
A sitting position permits maximum
lung excursion and chest expansion.
This method relaxes muscles and
increases the patient’s oxygen level.
Hypoxia triggers the drive to breathe in
the chronic CO2 retainer patient. When
administering oxygen, close monitoring
is very important to avoid uncertain
risings in the patient’s PaO2, which
could lead to apnea.
This conserves energy and avoids
necessary. overexertion and fatigue.
7. Teach patient about:
 

 pursed-lip breathing
 abdominal breathing
 performing relaxation
techniques
These measures allow patient to
 performing relaxation
participate in maintaining health status
techniques
and improve ventilation.
 taking prescribed medications
(ensuring accuracy of dose and
frequency and monitoring
adverse effects)
 scheduling activities to avoid
fatigue and provide for rest
periods

Nursing Evaluation:
After 7 hours of nursing intervention, the patient established a normal O2 of
97%, established RR of 14-18 cpm without nasal flaring, maintained effective
breathing pattern and with no signs of dyspnea with the verbalization, “hindi na ako
nahihirapan huminga”.