• No verbalized statement from the patient.

Subjective

• Shortness of breath
• pallor
• Rapid heart rate
• Pain
• Low blood pressure
Objective • Lab findings: RBC: 3.5 HGB: 10.3 HCT: 34
• Vital signs: Pulse Rate: 130bpm Respiratory Rate: 38cpm
• Blood Pressure: 80/60mmHg O2 Saturation: 90%

• Ineffective Breathing Pattern related to Decreased

lung expansion (air/fluid accumulation)
Assessment

• Within 8 hours of nursing interventions, the patient will be able

to establish a normal/effective respiratory pattern
Plan

•Assist patient with splinting painful area when coughing, deep breathing.
•Maintain a position of comfort, usually with the head of bed elevated. Turn to the affected side.
Encourage patient to sit up as much as possible.
•Maintain a calm attitude, assisting the patient to “take control” by using slower and deeper
respirations.
Interventions •Note chest excursion and position of the trachea.
•Check suction control chamber for a correct amount of suction

• After 8 hours of nursing interventions, the

patient established a normal/effective
Evaluation respiratory pattern