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College of Nursing: Independent: That Would Cause Breathing Respiratory Ailments in General

>Provide emotional support and reassurance >Encourage fluid intake and adequate nutrition >Monitor for signs of respiratory distress and report to nurse >Assist with ambulation and positioning >Monitor intake and output >Provide comfort measures Evaluation: Short Term: After 8 hours of nursing interventions, the patient was able to maintain oxygen saturation at 90-100% throughout hospitalization and demonstrate two breathing techniques to use during dyspneic episodes. Long Term: After 16 hours of nursing interventions the patient was able to establish a normal, effective respiratory pattern as evidenced by absence of cyanosis and hypoxia within normal acceptable range.

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Christine Pialan Salimbagat
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48 views2 pages

College of Nursing: Independent: That Would Cause Breathing Respiratory Ailments in General

>Provide emotional support and reassurance >Encourage fluid intake and adequate nutrition >Monitor for signs of respiratory distress and report to nurse >Assist with ambulation and positioning >Monitor intake and output >Provide comfort measures Evaluation: Short Term: After 8 hours of nursing interventions, the patient was able to maintain oxygen saturation at 90-100% throughout hospitalization and demonstrate two breathing techniques to use during dyspneic episodes. Long Term: After 16 hours of nursing interventions the patient was able to establish a normal, effective respiratory pattern as evidenced by absence of cyanosis and hypoxia within normal acceptable range.

Uploaded by

Christine Pialan Salimbagat
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Mindanao State University – Iligan Institute of Technology

Student: Salimbagat, Christine P. Group: __________


COLLEGE OF NURSING
Inclusive Dates of Duty: November 23-25, 2020
Patient: Mang Kanor Room No.: _______

NURSING CARE PLAN


Identified Problem: Difficulty breathing

Nursing Diagnosis: Ineffective Breathing Pattern related to hypoxia as evidence by shortness of breath and oxygen saturation of 85% on room air
CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION
Subjective: Short Term Objectives: Independent: Short Term:
 No data provided After 8 hours of nursing >Determine the presence of factors/physical > that would cause breathing (Goal Met) After 8 hours of
interventions the patient will conditions as noted in related factors impairments nursing interventions the
Objective: be able to: >Identify age of client who may be at >Respiratory ailments in general patient was able to:
 Patient’s oxygen  Maintain oxygen increased risk are increased in elderly such as  Maintain oxygen
saturation is 85% on saturation at 90- >Auscultate and percuss chest infectious pneumonias. saturation at 90-100%
room air 100% throughout >Note rate and depth of respirations and type >Evaluate presence of throughout
 Patient presents hospitalization of breathing pattern characteristics of breath sounds hospitalization
shortness of breath  Demonstrate two >Evaluate cough and presence of secretions and secretions  Demonstrate two
 Decreased breath breathing techniques >Note emotional responses >Indicating possible obstruction breathing techniques to
sounds of the lung to use during >Assess for concomitant pain/discomfort >Anxiety may be causing or use during dyspneic
(right base) upon dyspneic episodes >Encourage slower/deeper respirations, use exacerbating acute or chronic episodes within 8 hours
auscultation within 8 hours of pursed-lip technique and so on hyperventilation
 Productive cough Long Term Objectives: Long Term:
>monitor pulse oximetry >May restrict respiratory effort
with green sputum After 16 hours of nursing (Goal Met) After 16 hours of
>Emphasize the importance of good posture >To assist the client in taking nursing interventions the
 Evident flaring of the interventions the patient will
be able to: and effective use of accessory muscles control of the situation patient was able to:
nasal alae >To verify
 Patient is using his  Establish a normal,
effective respiratory Dependent: maintenance/improvement in  Establish a normal,
accessory muscles to >Administer nasal cannula (2 L/min) as oxygen saturation
help him breathe pattern as evidenced effective respiratory
by absence of prescribed by the doctor >To maximize respiratory effort pattern as evidenced by
 Vital sign: >Medicate with analgesics as appropriate
- Temp: 38°C cyanosis and absence of cyanosis
hypoxia within and hypoxia within
normal acceptable > Titrate to keep SaO2 greater normal acceptable
range Collaborative: than 90% range
>Assist with/review results of necessary >To promote deeper respiration
testing (e.g chest x-ray, lung volumes/flow and cough
studies and pulmonary function/sleep
studies)
>review laboratory data such as ABGs >To diagnose the
>Refer for general exercise program as presence/severity of lung
indicated diseases
>Encourage the client/SO to develop a plan for >Determine degree of
smoking cessation oxygenation and carbon dioxide
>Provide/encourage use of adjuncts such as retention
incentive spirometer >To maximize the client’s level
of functioning
>To provide appropriate referals
>To facilitate deeper respiratory
effort

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