NURSING CARE PLAN

Name of Client: Age: 46 _______Gender: Female__________ Ward/Room No. 1234___________Medical Diagnosis: Asthma_________
Address: 22 Halcion St., Brgy. Panatag, Mandaluyong City Attending Physician: Jaycee H. Santos, MD ________Chief complaint: Difficulty of breathing_
Inclusive Dates of Confinement: April 3, 2021-April 5, 2021 Health Care Agency: San Jose District Hospital____

NURSING DIAGNOSIS ANALYSIS GOALS AND NURSING RATIONALE EVALUATION

OBJECTIVES INTERVENTIONS

Ineffective Breathing Ineffective Breathing Goal: 1. Independent The goal set for the
Pattern related to Pattern is the state in After one (1) day of 1.1. Teach the client client was:
Anxiety as evidenced by: which the rate, depth, nursing intervention, the deep breathing To clear airways without
timing, rhythm, or pattern patient reports feeling exercises and coughing fatigue. 🟥Met
Subjective: of breathing is altered comfortable when ⬜Partially Met
technique
- Client sometimes cries and the body will likely breathing. ⬜Unmet
at the corner and not get enough oxygen
always thinks about to the cells. Causes and Objective: 1.2. Teach the client As evidenced by:
To allow the client to
what would happen to factors contributing to 1. After 3 minutes, the about pursed-lip
her family if she Ineffective Breathing client will state, 3 out participate in maintaining 1. After 3 minutes of
breathing, abdominal
suddenly passed away. Pattern include severe of 5 common health status to improve counseling, the
breathing and
- “Nangangati ang aking allergic reaction management for ventilation. client verbalized
performing relaxation
balat, ‘pag kinakamot (Asthma), anxiety, ineffective breathing at least 3
pattern by the help of techniques
ko ang aking balat, eto feelings of hopelessness strategies to
ay namumuti” and social isolation, a health care provider. To prevent fatigue and manage
abdominal wall 2. After 3 minutes, the 1.3.Schedule necessary Ineffective
client will demonstrate reduce O2 demands.
Objective: excursion during activities to provide Breathing Pattern.
-shortness of breath inspiration, expiration or adherence to at least periods of rest
- Cough both do not maintain 2 out of 3 treatment
- Rough and dry skin optimum ventilation for plans, by facilitation of 2. After 3 minutes of
2. Dependent
- Nasal flaring the individual. the nurse To remove pathogens nursing
2.1. Encourage sputum
- Crackles sound in and prevent spread of interventions, the
 lungs Anxiety, oxygenation expectoration Infection. client
- Use of accessory problems such as skin, demonstrated
muscles to breathe feelings of hopelessness to facilitate secretion adherence and
- Abdominal muscle aids and social isolation cooperation to 2
2.2. Perform postural movement.
client’s breathing treatment routines
drainage, percussion, for Ineffective
breathing pattern is
Measurements: and vibration Breathing Pattern.
compromised
BP - 120/ 80 mm Hg fluid intake insures
RR - 32 bpm oxygen transport to cells 2.3. Encourage fluid hydration and maintains
PR - 88 bpm is inefficient intake especially water moisture of the skin.
T - 37.2 ºC and fruit juices.
HT - 5’1” ft
Ineffective Breathing
WT - 50 kg
Pattern

REFERENCES:

Berman, A., Snyder, S., & Frandsen, G. (2022). Kozier & Erb’s Fundamentals of Nursing: Concepts, Practice, and Process (11th ed.). Pearson