Assessment Nursing Inference Planning Intervention Rationale Evaluation

Diagnosis
Subjective Ineffective Presence of Short Term Goal:  Asses and record  Adults breathe at a rate Short Term Goal:
Cues: Airway secretions in theAfter 6 hours of respiratory rate and of 10 to 20 breaths per After 6 hours of nursing
-patient states Breathing bronchi nursing intervention: depth at least every 4 minute on average. To intervention:
she has been  The patient will hours detect early signs of  The patient
extremely short maintain an respiratory compromise, maintained an
of breath for the Blockage of air effective it is important to act effective breathing
past 12 hours that will enter breathing pattern when there is a change in pattern as evidenced
the body as evidenced by breathing pattern. by relaxed breathing
Objective relaxed breathing  Place patient with  A sitting position permits at normal rate, depth
Cues: with normal rate proper body alignment maximum lung excursion and absence of
- irregular of 12-20 breaths for maximum breathing and chest expansion. dyspnea
breathing Producing pattern
per minute, depth  Patient indicated
- she use her insufficient air  Encourage  This method relaxes
and absence of feeling of
accessory dyspnea diaphragmatic breathing muscles and increases the comfortable when
muscle to help  Patient will patient’s oxygen level. breathing
her breathe.  Provide medications and  Beta-adrenergic agonist
Inability to indicates either
- She only state oxygen as per doctors medications relax airway Long Term Goal:
maintain clear verbally or
2-3 words order smooth muscles and
airway through behavior, After 3 days of nursing
before she stops feeling of cause bronchodilation to intervention the patient:
and has to  Encourage patient to open air passages.
comfortable when mobilize own secretions  Reported feeling
breathe again. breathing  To maintain a clear rested each day
- Vital signs with successful airway and to have
Obstruction Long Term Goal: coughing  Performed
BP: 150/80 heightened by After 3 days of adequate clearance of diaphragmatic
P: 112 bronchospasm nursing intervention secretions pursed-lip breathing
 Ambulate patient as
RR: 36 the patient will:  Ambulation can further  Carried out ADLs
tolerated with doctors
Oxygen Sat:  Reports feeling break up and move and breathing
order 3x daily.
85% rested each day secretions that block the pattern are remained
 Performs  Encourage frequent rest airways. normal.
Stimulate
parasympathetic
diaphragmatic periods and teach patient  Extra activity can worsen  Patient oxygen sat
pursed-lip to pace activity shortness of breath. are 90-100%
muscarinic2 breathing Ensure the patient rests
receptors  Carries out ADLs  Teach patient about: between strenuous
and breathing activities.
patter remains - pursed-lip breathing  These measures allow
normal. - abdominal breathing patient to participate in
released  Patient oxygen - performing maintaining health status
presence of sat will be90- relaxation technique and improve ventilation.
allergen 100% throughout
hospitalization.

Wayne, G.
(2019)
Nurseslabs
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