ASSESSMENT NURSING EXPECTED OUTCOME NURSING RATIONALE

DIAGNOSIS INTERVENTION
Objective:  -Pt oxygen  Assess and  The average rate of
Ineffective saturation will record respiration for adults
respiratory rate is Breathing Pattern be 90-100% respiratory rate is 10 to 20 breaths per
68 breaths/min and related to mild throughout and depth at minute. It is important
oxygen saturation is cyanosis hospitalization. least every 4 to take action when
82%  -Pt respiratory hours. there is an alteration
rate will be 12-  Assess ABG in the pattern of
20 breaths per levels, according breathing to detect
minute to facility policy. early signs of
throughout  Observe for respiratory
Zamoro hospitalization breathing compromise.
patterns.  This monitors
oxygenation and
ventilation status.

Unusual breathing
patterns may imply an
underlying disease
process or
dysfunction. Cheyne-
Stokes respiration
signifies bilateral
dysfunction in the
deep cerebral or
diencephalon related
with brain injury or
metabolic
abnormalities.
Apneusis and ataxic
breathing are related
with failure of the
respiratory centers in
the pons and medulla.