DAVAO DOCTORA COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE

PLAN

Name of Patient: Patient Nam Kyung Jin Date of Admission: _February 9, 2023_Room: 405B
Age: 68 y/o Sex: _Male Chief Complaint: _Shortness of Breath ______
Attending Physician: Dr. Miranda

OBJECTIVE NURSING
NURSING ASSESSMENT NURSING DIAGNOSIS RATIONALE EVALUATION
INTERVENTIONS
Date: February 9, 2023 Ineffective breathing After 8 hours of nursing ● Place patient with proper ● A sitting position permits Date: February 9, 2023
Time: 9:45 AM pattern related to intervention the patient will: body alignment for maximum lung excursion and Time: 5:45 PM
maximum breathing pattern. chest expansion.
shortness of breath
Subjective: ● The patient will maintain GOAL MET
“Medyo nahihirapan akong an effective breathing ● Encourage sustained deep ● These techniques promote
SCIENTIFIC BASIS:
huminga nang dahil dito sa pattern, as evidenced by breaths by: deep inspiration, which After the nursing
lumalaki kong tiyan”. relaxed breathing at the - Using demonstration: increases oxygenation and intervention the patient was
Breathing pattern
normal rate and depth and highlighting slow inhalation, prevents atelectasis. able to:
alteration may also
Objective: absence of dyspnea. holding end inspiration for a Controlled breathing methods
transpire in a number of
-restless few seconds, and passive may also aid slow ● The patient maintains an
circumstances from heart
● The patient’s respiratory exhalation respirations in patients who effective breathing pattern, as
failure, hypoxia, airway
-difficulty sleeping rate will remain within - Utilizing incentive are tachypneic. Prolonged evidenced by relaxed
obstruction, fatigue and
established limits. spirometer Expiration prevents air breathing at the normal rate
pneumonia and many
-smoker - Requiring the patient to trapping. and depth and absence of
more. the body weakness
● The patient will indicate, yawn dyspnea.
or fatigue may changes
-alcoholic either verbally or through
position of the body that
behavior, feeling comfortable ● Encourage diaphragmatic ● This method relaxes ● The patient‘s respiratory
Vital Signs: prevents lung expansion, when breathing. breathing for patients with muscles and increases the rate remains within
BP: 140/90 mmHg and bronchial secretion, chronic disease. patient‘s oxygen level. established limits.
RR: 23 cpm that trigger an ● The patient will perform
PR: 95 bpm inadequate ventilation diaphragmatic pursed-lip ● Evaluate the ● This training improves ● The patient indicates,
Temp: 37.5 response and increase breathing. appropriateness of inspiratory conscious control of either verbally or through
O2 Sat: 96% the sensation of muscle training. respiratory muscles and behavior, feeling comfortable
dyspnea. ● The patient will inspiratory muscle strength. when breathing.
demonstrate maximum lung
expansion with adequate ● Provide respiratory ● Beta- adrenergic agonist ●The patient performs
 ventilation. medications and oxygen, per medications relax airway diaphragmatic pursed-lip
REFERENCE: doctor‘s orders. smooth muscles and cause breathing.
bronchodilation to open air ●The patient demonstrates
Herdman, H. & Kamitsura, passages. maximum lung expansion
S. (2018). Nursing with adequate ventilation.
Diagnosis, Definitions, and ●Encourage frequent rest ● Extra activity can worsen
Classification 2018-2020 periods and teach the patient shortness of breath. Ensure
(11th
to pace activity. the patient rests between
edition) Thieme. strenuous activities.

● Encourage small frequent ● This prevents crowding of

meals. the diaphragm.

ADDITIONAL REFERENCES:
References: Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2011).Nurse’s pocket guide, diagnoses, prioritized interventions, and rationales. (12 ed.). F A Davis
Co.
CAMPILLO, NICOLE C
BBN/DTS/2020 NAME OF STUDENT