Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:(none) Ineffective breathing Choose: 1. Establish rapport. 1. To gain pt.s trust. Patient will demonstrate
pattern r/t presence of Patient will demonstrate 2. assess pt.s condition 2. To obtain baseline pursed-lip breathing and
Objective: secretions AEB pursed-lip breathing and 3. VS monitor and record data diaphragmatic
wheezing upon productive cough and diaphragmatic 4. Auscultate breath 3. Serve to track breathing.
inspiration and dyspnea breathing. sounds and assess important changes
expiration airway pattern 4. to check for the Patient will manifest
dyspnea Patient will manifest 5. Elevate head of the bed presence of signs of decreased
coughing, sputum is signs of decreased and change position of adventitious breath respiratory effort AEB
yellow and sticky respiratory effort AEB the pt. every 2 hours. sounds absence of dyspnea
tachypnea, prolonged absence of dyspnea 6. Encourage deep 5. To minimize
expiration breathing and coughing difficulty in Patient will verbalize
tachycardia Patient will verbalize exercises. breathing understanding of
chest tightness understanding of 7. Demonstrate causative factors and
suprasternal causative factors and diaphragmatic and 6. To maximize effort demonstrate behaviors
retraction demonstrate behaviors pursed-lip breathing. for expectoration. that would improve
restlessness that would improve 8. Encourage increase in breathing pattern
anxiety breathing pattern fluid intake 7. To decrease air
9. Encourage trapping and for (change will to shall then
cyanosis
opportunities for rest efficient breathing. shift to past tense)
loss of consciousness
and limit physical 8. To prevent fatigue.
activities.
10. Reinforce low salt, low 9. To prevent situations
fat diet as ordered. that will aggravate
the condition

10. To mobilize
secretions.