ASSESSMENT 

DIAGNOSIS  PLANNING  INTERVENTION RATIONALE  EVALUATION 

S 
Subjective:  Ineffective After 1-2 hours Independent:  Independent: After 2 hours of nursing
  breathing pattern of nursing care, care, the patient has
“Nurse,  nahihirapan related to spasm of the patient will Place the patient in This can help the regular breathing
po  akong  huminga. respiratory muscles report comfort a sitting position.  patient to breath pattern with 20 cpm
Para  akong sinasak as evidenced by in properly by relaxing respiratory rate and
 
al.” As verbalized dyspnea, tachypnea, breathing and rel your body. A sitting 98% Spo2. The patient
by the patient.  and nasal flaring position permits reported comfort in
ief of respiratory  
    maximum lung breathing and relief of
muscle spasm as  
Objective:  The excursion and chest muscle spasm. 
  musculoskeletal manifested by
expansion that aids
Vital signs system benefits respiratory rate in respiration.
obtained.   greatly from of 20 cpm and
BP: 130/70 mmHg breathing with Spo2 of 98%,
CR: 120 regular respiratory with regular Provide well
RR: 23 cpm mechanics. In both breathing ventilated To prevent
Temperature: postural and spinal pattern. environment or suffocation and
37.8 degrees stabilization, room for the patient improve air flow
Celsius,  respiratory   
 Spo2: 95%  mechanics are  
  important. Both Assess and record The average rate
Presence of lock jaw appropriate   respiratory rate and of respiration for
and stiff neck posture and spinal depth at least adults is 10 to 20
Bounding of radial stabilization breaths per minute.
every 4 hours. 
pulses with necessitate healthy It is important to
occasional increase respiratory   take action when
in blood pressure mechanics. The
there is an alteration
Dyspnea major respiratory in breathing
Nasal flaring muscles interact in patterns to detect
Use of accessory a dynamic way. early signs of
muscles One's dysfunction compromise on the
Retractions can cause the respiratory system.
other's to
malfunction (co-
dependency). Other
muscles must Work of breathing
Assess for the increases greatly
function to move use of accessory as lung compliance
the ribs up and
muscle. decreases. Use of
down during
respiration, accessory muscles
therefore the indicate altered
cervical and respiration. Noting
thoracic spine must this will provide
be  stabilized. Due data regarding
to adaptive patient’s condition
contraction and what
patterns based on
intervention should
muscles' force-
length curve, the be given.
rib cage may
present mechanical
modifications These signs
leading to Monitor for signify an increase
insufficient
retractions or in respiratory
respiratory
flaring of nostrils.  effort. 
dysfunction,
effecting all  
muscles involved
such as the
diaphragm,
intercostal, and Pulse oximetry
abdominals. As a is a helpful tool
result, it's possible Utilize pulse
to detect
that the power of oximetry to check
alterations in
inspiration and oxygen saturation
oxygenation
expiration in and pulse rate.
initially; but, for
people with neck
CO2 levels, end-
pain and spasm of
tidal CO2
the respiratory
muscle in tetanus is monitoring or
reduced.  arterial blood gases
(ABGs) would
require obtaining

Encourage slow and Controlled

deep breathing. breathing methods
Teach and instruct can also aid to slow
the patient how to respirations in
perform deep patients who has
breathing exercises tachypnea.
and purse-lip
technique.
Extra activity can
worsen shortness of
Encourage rest breath. Ensure the
period between patient has adequate
activities and rests to conserve
prohibit heavy energy and oxygen
activities. consumption
 Patients diagnosed
with tetanus may
Implement seizure
experience seizures.
precaution in
So, implementing
chances of episodes
seizure precautions
of seizures. (Bed in
and preparing
lowest position with
equipment readily
side rails up and
available will
seizure pads against
prevent serious
the side rails.
complications from
Patient must wear
seizures to happen.
loosened clothing,
pillow under the
head and oxygen
and suction
apparatus available) Dependent:

Will provide
additional oxygen
Dependent: 
for consumption
Hook patient on and will aid in
oxygen inhalation respiration.
per nasal cannula as
indicated.
Diazepam could
 
help the patient to
Administer relieve muscle
medication, spasm and seizure
specifically which are the most
diazepam as common symptoms
ordered by the manifested by the
physician.    patient.
This allows an
immediate action in
case
Secure consent for respiratory
standby intubation emergency happens
in case of to the
respiratory patient in order to
emergency as prevent serious
indicated problems in
respiration that may
be life-threatening
 
Collaborative:
To find out what
Collaborative:  forces are at play
and to facilitate
Monitor patient’s relay of information
condition by to the physician in
collaborating with order to formulate
other health care appropriate nursing
team members in and medical
performing intervention.
different laboratory
and diagnostic
procedures
indicated.