Nursing Care Plan #1 Ineffective breathing

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Ineffective breathing Short term: Independent: Independent: Short term:

“Nahihirapan po ako pattern due to loss of After 2 hours of nursing 1.Monitored and record 1. To detect early signs After 2 hours of nursing
huminga at sumasakit blood as manifested by intervention the patient respiratory rate and of compromise on intervention the patient
din yung saksak sakin.” the stab wounds. will be able to display an depth at least every 4 the respiratory system. was able to display an
as verbalized by the effective breathing hours. effective breathing
patient. pattern. 2. Monitor for changes pattern.
2.Assessed breath in lung sounds,
Long term: sounds and other vital respiratory rate and
After 8 hours of nursing signs. depth, and oxygen
Objective: intervention the patient saturation closely for
BP: 120/80 will be able to maintain 3. Reviewed ABG worsening or Long term:
PR: 72bpm an effective breathing levels. improvement. After 8 hours of nursing
RR: 30 pattern with normal intervention the patient
TR: 36.3 respiratory rate, depth, 4. Observed breathing 3.To monitor the amount was able to maintain an
Pain scale: 8/10 and oxygen saturation. patterns. of oxygen and carbon effective breathing
SOB The patient’s ABG dioxide in the blood. pattern with normal
levels will return to and 5. Assessed for pain. respiratory rate, depth,
remain within normal 4.Unusual breathing and oxygen saturation.
limits. 6. Encouraged used of patterns may imply an The patient’s ABG
stress management underlying disease levels returned to and
techniques such as deep process or dysfunction. remained within normal
breathing exercises. limits.
5.To prevent from
getting adequate Goal was met.
Dependent: oxygenation. Pain can
7.Administered oxygen cause increased blood
therapy as ordered. pressure, heart rate, and
ineffective breathing
8.Assisted in performing patterns. Some patients
diagnostic laparoscopy. breathe very shallowly
to guard against pain.
6. Refocuses attention,
may enhance coping
abilities.

Dependent:
7. To provide adequate
oxygen in the body
which increases blood
flow thus relieving pain.

8. To determine whether
or not the diaphragm had
been penetrated.