Assessment Nursing diagnosis

Scientific Explanation

Planning Nursing Intervention Rationale Evaluation

Subjective Data:“medyo nahihirapan akong huminga”

Objective data: Looks pale Restlessnes

s Fatigue Use

accessory muscles when breathing

(+) wheezes With

productive cough

On high back rest

Profound breathing pattern

Vital signs:T-36 P-78 R-28 BP-100/60mmHg

Ineffective breathing pattern related to bronchospasm 2 BAiAE

exposure to triggers

the bronchi (large airways) contract into spasm

Inflammation

narrowing of the airways

excessive mucus production

coughing

breathing difficulties

Short term:After 3-4 hrs of effective nursing intervention the patient will established a normal-effective respiratory pattern AEB:

(-)Restlessness (-)fatigue (-)Use accessory

muscles when breathing

With productive cough

On moderate high back rest

Regular breathing pattern

Vital signs:T-36 P-78 R-22-24 BP-100/60mmHg

Long term:During the whole duration of hospitalization the patient can/will:

Verbalize awareness of causative factors.

Initiate needed lifestyle changes

Establish rapport to patient and SO.

Auscultate chest, noting presence/character of breath sounds, presence of secretions.

Note rate and depth of respirations

Review Laboratory data.

Administer O2 indicated for underlying pulmonary condition

Elevate HOB as appropriate.

Maintain a calm attitude while dealing with client and SO.

Assist client in the use of relaxation technique.

Assist and demonstrate deep breathing and coughing exercise.

Encourage position of comfort. Reposition

To gain trust and have a better NPI.

To identify etiology/ precipitating factors.

To provide relief .

To promote physiologic/psychologic ease of maximal inspiration

To limit level of anxiety.

To assist client in taking control of the situation.

Short term:Goal met as evidenced by:

(-)Restlessness (-)fatigue (-)Use

accessory muscles when breathing

With productive cough

On moderate high back rest

Regular breathing pattern

Vital signs:T-36 P-78 R-23 BP-100/60mmHg

Long term Goal met as evidenced by: able to

Verbalize awareness of causative factors.

Initiate

Demonstrate appropriate coping behaviors.

Maintained normal/stable Vital signs

Experienced free from signs of hypoxia.

every 2 hrs..

Health teachings: Review etiology and

possible coping behaviors

Teach conscious control of RR as appropriate.

Recommend energy conservation techniques and pacing of activities.

Encouraged adequate rest periods between activities

Collaborative: Nebuliza

tion as ordered

Administer hydrocortisone as ordered.

To limit fatigue.

> To decreased secretions and allow ease from maximal inspiration

needed lifestyle changes

Demonstrate appropriate coping behaviors.

Maintained normal/stable Vital signs

Experienced free from cyanosis and other signs of hypoxia.

Assessment Nursing diagnosis Planning Nursing Intervention EvaluationSubjective Data:“medyo nahihirapan akong huminga”

Objective data: Looks pale Restlessness Fatigue Use accessory

muscles when breathing

(+) wheezes With

productive cough

On high back rest

Profound breathing pattern

Vital signs:T-36 P-78 R-28 BP-100/60mmHg

Ineffective breathing pattern related to bronchospasm 2 BAiAE

Short term:After 3-4 hrs of effective nursing intervention the patient will established a normal-effective respiratory pattern AEB:

(-)Restlessness (-)fatigue (-)Use accessory

muscles when breathing

With productive cough On moderate high back

rest Regular breathing

pattern Vital signs:

T-36 P-78 R-22-24 BP-100/60mmHg

Long term:During the whole duration of hospitalization the patient can/will:

Verbalize awareness of

Establish rapport to patient and SO.

Auscultate chest, noting presence/character of breath sounds, presence of secretions.

Note rate and depth of respirations

Review Laboratory data.

Administer O2 indicated for underlying pulmonary condition

Elevate HOB as appropriate.Maintain a calm attitude while

dealing with client and SO.Assist client in the use of

relaxation technique.

Assist and demonstrate deep breathing and coughing exercise.

Encourage position of comfort. Reposition every 2 hrs.

.Health teachings: Review etiology and possible

Short term:Goal met as evidenced by:

(-)Restlessness (-)fatigue (-)Use accessory

muscles when breathing

With productive cough

On moderate high back rest

Regular breathing pattern

Vital signs:T-36 P-78 R-23 BP-100/60mmHg

Long term Goal met as evidenced by: able to

Verbalize awareness of causative factors.

Initiate needed lifestyle changes

Demonstrate appropriate

causative factors. Initiate needed

lifestyle changes Demonstrate

appropriate coping behaviors.

Maintained normal/stable Vital signs

Experienced free from signs of hypoxia.

coping behaviors Teach conscious control of RR

as appropriate. Recommend energy

conservation techniques and pacing of activities.

Encouraged adequate rest periods between activities

Collaborative: Nebulization as

ordered Administer

hydrocortisone as ordered.

coping behaviors. Maintained

normal/stable Vital signs

Experienced free from cyanosis and other signs of hypoxia.