SCIENTIFIC

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

EXPLANATION

Subjective: Ineffective It is considered Goal: Dependent Goal met:

breathing the state in which After 4hrs of  Monitor v/s  To assist in The patient will
“Nahihirapan pattern the rate, depth, nursing creating an achieve
huminga ang timing, rhythm, or interventiona accurate effective
anak ko” as pattern of the pt will breath diagnosis and breathing
verbalized by the breathing is normally monitor pattern as
patient altered. When effectiveness evidenced by
the breathing of medical respiratory rates
Objective: pattern is treatment between 12 to
ineffective, the  Assess and  Provide for 20 breaths per
 Breath body will likely record baseline data minutes, oxygen
sounds not get enough respiratory rate in evaluating saturation
noted: oxygen to the every 4 hrs respiratory between 88 to
Wheezes cells. Respiratory function 92%, and
failure may be verbalize ease
 Irregular correlated with  Observe  Provide you of breathing.
breathing variations in breathing with greater
respiratory rate, pattern sense of
 V/S taken as abdominal and mental clarity
follows: thoracic patterns. it can also
help you
Breathing pattern sleep better,
T: 36.8 alteration may digest food
P: 103 also transpire in more
R: 24 several efficiently
BP: 90/60 circumstances improve your
from heart failure, body, immune
hypoxia, airway response and
obstruction, reduce stress
diaphragmatic levels
paralysis,  Auscultate  Presence of
infection, breath sounds adventitious
neuromuscular breath
impairment, sounds may
trauma or indicate
surgery resulting developing
in  Assess the complications
musculoskeletal client the use  For patients
impairment and of relaxation relieve
pain, cognitive technique heaviness of
impairment and breath
anxiety, diabetic  Assist and
ketoacidosis, demonstrate  Leads to early
uremia, thyroid deep breathing identification
dysfunction, and coughing and treatment
peritonitis, drug exercises of impending
overdose, AIDS, respiratory
acute alcohol failure
withdrawal,
cardiac surgery,
cholecystectomy, Independent
liver cirrhosis,  Administer the
craniocerebral prescribed  To treat
trauma, disc antibiotics bacterial
surgery, medications infection if
lymphomas, this is the
renal dialysis, underlying
seizure cause of the
disorders, spinal patient’s
cord injuries, pleural
mechanical effusion.
ventilatory  Prepare the
assistance, and patient for tube  Tube
pleural toracsotomy or thoracostomy
inflammation. chest drain includes
insertion thoracentesis
and the
placement of
a draining
tube to the
pleural space
to drain the
excess fluid.
It may take
several days
before the
tube is
removed. On
the other
hand, a
pleural drain
insertion
involves long
term drain for
chronic
pleural
effusion. Both
are minimally
invasive
 Prepare the procedures.
patient for  For effusions
surgery as not relieved
ordered by drainage
or pleural
sclerosis,
surgery may
be warranted
and they are
divided into
two: Video
assisted
thorascopic
surgery
(VATS) – a
minimally
invasive
procedure
involving 1 to
3 small
incisions
under scope
guidance and
the
introduction of
sclerosing
agent to
prevent
pleural
effusion build-
upTraditional
thoracotomy
(open
thoracic
surgery) –
performed
 thru a 6-8
incision into
the chest
cavity to
evacuate
infected
tissue and
remove
fibrous build-
up causing
pleural
effusions.
 A variety of
medication
are prepared
 Perform to manage
nasotracheal specific
suctioning as problems
necessary most promote
specially if clearance of
cough airway
ineffective secretions
and may
reduce airway
resistance