Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective breathing Short Term Goal: Independent: Short Term Evaluation:
pattern related to
“Hindi ako makahinga changes in oxygenation After 30-40 minutes of 1. Assess the respiratory 1. To obtain baseline After 40 minutes of
at para akong nauupos as evidenced by acute nursing interventions, the status of the patient data and evaluate nursing interventions, the
na kandila” as onset of breathing client will be able to have including rate and depth. respiratory status. goals to improve the
verbalized exhaustively difficulty. an improvement in client’s respiratory
by the patient. breathing pattern as 2. Observe characteristics of 2. To provide insight condition were:
evidenced by: breathing pattern. (uses into the work of
● Difficulty accessory muscles, nasal breathing and ✓ Met
breathing at ➢ Normal and flaring, pulsed-lip adequacy of _ Partially Met
rest. effective breathing, etc.) breathing pattern. _ Unmet
● Mild fatigue. respiratory
pattern, if not 3. Auscultate and percuss 3. Abnormal breath As evidenced by:
Objective: fully improved. chest, describing sounds are indicative
● History of ➢ Normal O2 presence/ absence and of numerous ➢ Client’s
hospitalization saturation level. character of breath problems and must be demonstration of
due to COPD. ➢ Being relaxed. sounds. evaluated further. normal and
● No ambulation ➢ Verbalization of effective
for several understanding of 4. Note for the color of the 4. Pallor, duskiness, or respiratory
days. the causative skin and mucous cyanosis indicates the pattern.
● Feeling weak. factors and membranes. need for ➢ The patient has
● Obese appropriate supplemental oxygen normal O2
● Active smoker interventions. interventions. saturation level of
for 30 years. ➢ Participation in 5. Elevate the head of the 5. Promotes 96%.
(already quit 2 the treatment bed or have the client sit physiological and ➢ Patient is relaxed
years ago). regimen up on a chair/ side of the psychological ease of and resting.
● Hypertensive (breathing bed. maximal inspiration. ➢ The patient
● Hyperlipidemic exercises and use verbalized
● History of of oxygen). 6. Encourage deeper and 6. To promote oxygen understanding of
myocardial slower respirations and diffusion. causative factors
infarction. the use of pursed-lip and appropriate
Long Term Goal: technique. interventions.
➢ The patient
 After 1-2 weeks of 7. Provide pulse oximeter 7. To verify cooperated in the
nursing interventions, the and monitor O2 maintenance/ treatment regimen
patient will be able to saturation levels. improvement in O2 (breathing
have a fully improved saturation. exercises and use
breathing pattern as of oxygen
evidenced by: 8. Note for emotional state 8. Emotional changes delivery method.
can accompany a
➢ Complete condition or
recovery and has a aggravate the Long Term Evaluation:
stable normal ineffective breathing
breathing pattern. pattern. After a week of
➢ Verbalization of nursing interventions, the
his understanding 9. Maintain a calm attitude 9. To reduce/prevent goals to improve the
regarding the while dealing with the anxiety. client’s condition were:
condition. client.
➢ Verbalization of ✓ Met
his understanding 10. Assist the client with the 10. To reduce/ prevent _ Partially Met
of the different use of relaxation anxiety and promote _ Unmet
techniques to techniques. relaxation.
manage his ➢ The patient is
condition. 11. Encourage adequate rest 11. This helps limit showing complete
and limit activities. oxygen needs and recovery with
consumption. stable normal
breathing pattern
12. Vital signs are ➢ Client verbalized
12. Monitor vital signs affected by changes understanding
regularly. in oxygenation. about his
condition.
13. To prevent ➢ Verbalized
13. Encourage ambulation. atelectasis. understanding of
the different
techniques to
Dependent: manage his
1. To help the patient condition.
1. Administer oxygen breathe.
delivery methods,
 depending on the order of
the doctor. 2. To alleviate signs and
2. Administer prescribed symptoms.
medications.

Interdependent/
Collaborative:
1. To determine the
1. Refer the patient to a levels of oxygen and
Medical Technologist for carbon dioxide in the
ABG testing. blood.

2. To identify the
2. Refer the patient to a presence/ absence of
Radiologist for Chest X- disease and assess the
ray. respiratory structures.