Date &

Time Cues Need Nursing Diagnosis Patient Outcome Nursing Intervention Implementation Evaluation

09/20/2022 Subjective: A Ineffective breathing 1. Monitor and record Vital signs 1 09/20/2022
At the end of the 8-hour
“Mao ra japon, luya pattern related to R – To obtain sufficient data. Inadequate
C nursing intervention, the
gyapon.” As fatigue as evidenced oxygenation causes increase PR. 11:00 PM
3 T patient indicates either
: verbalized by the by tachypnea. verbally or through 2. Monitor oxygen saturation and “Goal unmet”
watcher. I 2
0 behavior, feeling ABGs. Note the trend of these
V R - One of the vexing At the end of the 8-hour
0 comfortable when values.
Objective: things about certain
breathing. R - These values reveal information about nursing intervention, the
PM I common health
• PR – 116 complaints is the range the severity of the patient’s condition. patient was not able to
bpm T of possible underlying Worsening values may be a sign of
verbalize or display a
feeling of comfort when
• RR – 30 cpm Y causes. For example, respiratory failure in a deteriorating
feeling short of breath is breathing.
• Use of / perfectly normal after a
situation.
accessory burst of vigorous
E 3. Position in a semi fowler. 3
muscles to exercise. But for some
X people, even mild R – To maximize lung expansion.
breathe
exertion can trigger a
E sensation of 4. Administer oxygen as ordered.
breathlessness, or what 4
R R – Supplemental oxygen helps reduce
doctors call dyspnea. hypoxemia and relieve respiratory distress.
C It’s often accompanied
by symptoms such as
I fatigue and 5. Encourage sustained deep breaths. 5
lightheadedness. Techniques include
S
Tachypnea on the other (1) using demonstration: highlighting
E hand is the feeling of slow inhalation, holding end
rapid and shallow inspiration for a few seconds, and
breathing. While having
passive exhalation;
tachypnea, you may
also have other (2) utilizing incentive spirometer;
symptom called and
dyspnea. (3) requiring the patient to yawn.
R - These techniques promote deep
Reference: Corliss, J. inspiration, which increases oxygenation
(2022, April 1). and prevents atelectasis. Controlled
Unmasking the varied
breathing methods may also aid slow
causes of
breathlessness and respirations in tachypneic patients.
fatigue. Harvard Health. Prolonged expiration prevents air trapping.
Retrieved September
25, 2022, from 6. Evaluate the appropriateness of
https://www.health.harv inspiratory muscle training. 6
ard.edu/heart- R - This training improves conscious control
health/unmasking-the-
of respiratory muscles and inspiratory
varied-causes-of-
breathlessness-and- muscle strength.
fatigue#:%7E:text=But
%20for%20some%20p 7. Teach the patient pursed-lip
eople%2C%20even,lun breathing. 7
g%20issues%20are%2 R - Pursed-lip breathing is a technique that
0to%20blame. allows for controlled ventilation. The breath
is inhaled through the nose then slowly
exhaled through pursed lips allowing for a
prolonged expiration. Research shows this
is thought to support opening the airways
and preventing CO2 trapping.

8. Assist patient in the use of relaxation

8
technique.
R – To provide relief of causative factors.

9. Stay with the patient during acute

episodes of respiratory distress. 9
R - This will reduce the patient’s anxiety,
thereby reducing oxygen demand.

10. Avail a fan in the room.

R - Moving air can decrease feelings of air 10
hunger.
References:
Corliss, J. (2022, April 1). Unmasking the varied causes of breathlessness and fatigue. Harvard Health. Retrieved September 25, 2022, from
https://www.health.harvard.edu/heart-health/unmasking-the-varied-causes-of-breathlessness-and-
fatigue#:%7E:text=But%20for%20some%20people%2C%20even,lung%20issues%20are%20to%20blame.
Ineffective Breathing Pattern Nursing Diagnosis & Care Plan – RNlessons. (n.d.). Retrieved September 25, 2022, from https://rnlessons.com/ineffective-
breathing-pattern-nursing-diagnosis-care-plan/
Wayne, G. B. (2022, March 19). Ineffective Breathing Pattern Nursing Care Plan. Nurseslabs. Retrieved September 25, 2022, from
https://nurseslabs.com/ineffective-breathing-pattern/
CLUSTERING OF CUES ACCORDING TO GORDON’S 11 FUNCTIONAL HEALTH PATTERNS

Health Perception/Health Nutritional/Metabolic Elimination Activity/Exercise Cognition/Perceptual Sleep/Rest

Management
• NGT for feeding and • With bed pan and • Fatigue
medication Diaper • Rapid pulse
• Use of accessory
muscles to breathe
• Cannot dress alone
• Shortness of breath
noted
• Examination: a.
Demonstrated
ability for
Feeding: IV
Dressing: IV
Cooking: IV
Bathing: IV
Toileting: IV
• Range of motion
(joints) : III

VS:
• PR: 116 bpm
• RR: 30 cpm
Self-Perception/Self- Role/Relationship Sexual/Reproductive Coping/Stress Tolerance Value - Belief
Concept