Assessment Nursing Diagnosis Planning Nursing Intervention Rationale Evaluation

Subjective: Ineffective breathing Short term goal: Independent: GOAL MET

pattern related to pain After 12-24 hours of
“Nahihirapan ako nursing intervention the 1. Identify etiology or Understanding the After 12-24 hours of
huminga kasi sumasakit patient will be free of precipitating factors. cause is necessary for nursing intervention the
sugat ko tuwing dyspnea choice of therapeutic patient was free of
humihinga ako” as measures. dyspnea
verbalized by the Long term goal:
patient. After 7 days of nursing 2. Monitor vital signs. After 7 days of nursing
intervention the patient Monitoring the vital intervention the patient
will maintain a patent signs is necessary to maintained a patent
Objective: airway evaluate the degree of airway
compromise.
- respiratory rate of 30 3. Assess lung sounds,
- dyspnea respiratory rate and
- alteration in depth of effort and the use of Respiratory rate less
breathing accessory muscles. than 12 or more than
- pursed lip breathing 24 or use of accessory
- restlessness muscles indicate
-facial grimace distress. Diminished
lung sounds indicate
possible poor air
movement and
4. Evaluate respiratory impaired gas exchange.
function, noting rapid or
shallow respirations,
dyspnea and changes in
vital signs. Respiratory distress and
changes in vital signs
occur as a result of
physiologic stress and
pain.
6. Encourage adequate
rest and limit activities
within client’s level of
tolerance. Promote a
calm and restful Helps limit oxygen
environment. needs and
consumption.
Dependent:

1. Administer
supplemental oxygen as
ordered by the
physician. Supplemental oxygen
decreases hypoxia.
2. Administer
medications as
prescribed by the
physician. To treat underlying
conditions.