ASSESSMENT/ DIAGNOSIS PLANNING INTERVENTION EVALUATION

PROBLEM RATIONALE OF THE DESIRED BEHAVIORAL NURSING RATIONALE

CUES/NRSG. DX PROBLEM OUTCOME(S) OUTCOME(S) INTERVENTIONS
Subjective Data: Presence of After a week of After 8 hours of Independent: After a week of
“Inday akong ginhawa secretions in the nursing nursing - Assess patient’s -Manifestation of nursing
ba kay kuwang bronchi will result into intervention, the intervention the respiratory respiratory distress intervention the
kuwang ra, lisud e a blockage of air that patient will patient will be status every 2 to include shortness patient was able
ginhawa sugod pa ni will enter the body maintain a able to maintain: 4 hours as of breath, to maintain
gahapun” as verbalize and thus producing respiratory rate 1. Demonstrate indicated and Tachypnea, respiratory rate
by the patient insufficient air needed within normal two breathing notify any changes in mental within normal
by the body. And limits and techniques to abnormal status and the use range in 20 cpm
Objective data: inability to maintain demonstrate use during findings. of accessory and
 The patient stops clear airway. This improvement of dyspneic muscles. demonstrate
and breath again obstruction is further breathing episodes. - Auscultate -Decreased breath improvement of
every after 2-4 heightened by pattern. breath sounds sounds, crackles, breathing
words bronchospasm due to 2. Verbalized two every 2 to 4 wheezes, and pattern as
 Dyspnea the contraction of the ways on how to hours as rhonchi can be evidence by
 Wheezing upon muscles in the prevent COPD indicated. observed and must performing
inspiration and bronchi. This is exacerbation. be reported pursed lip
expiration caused the promptly for breathing and
 Using of accessory parasympathetic 3. Manifest signs immediate deep breathing
muscle in breathing stimulation of the of decreased of treatment. exercise.
 Tachypnea and muscarinic2 receptors respiratory - Elevate head of -To minimize
irregular as well as by chemical effort as the bed and difficulty in
 Coughing sputum is mediators released in evidence by position of the breathing
yellow and sticky response to the absence of patient every 2
presence of allergen. dyspnea hours.
 Restlessness
- Encourage deep
 Cyanosis
4. Verbalize breathing - To maximize effort
 Oxygen saturation at understanding exercise and for expectoration.
87% of causative coughing
Vital Signs factors and exercise
HR- 113 bpm demonstrate - Demonstrate
BP- 150/86 mmHg behaviors that diaphragmatic - To decrease air
RR- 36 cpm would improve and pursed lip trapping and for
T- 37.5 °C breathing breathing efficient breathing.
pattern - Encourage
Nursing Diagnosis:
Ineffective breathing increase in fluid - To prevent fatigue
pattern related to 5. Demonstrate intake
presence of pursed lip - Encourage
secretions as breathing opportunities for - To prevent
evidence by exercise and rest and limit situations that still
productive cough, diaphragmatic physical aggravate the
dyspnea, and use of breathing activities. condition
accessory muscle
Dependent:
- Administer
corticosteroids - To help improve
and patients breathing
bronchodilator and for treatment
medicine as
prescribe by the
physician

Collaborative:
- Refer the client
to a dietician - For proper
and or support counselling and
group intake of caloric
needs