JENNIFER RHAE J.

LIM 3NU04 GROUP 2

ASSESSMENT Subjective: nahihirapan pa din ako huminga na parang lalo ko nararamdaman yung sakit dito sa pinasukan nila kanina sa bandang dibdib ko as verbalized by the patient Objective: RESPIRATORY RATE: 25 cpm PAIN SCALE: 10 states 2-3 words before he stops and has to breathe again. DIAGNOSIS Ineffective breathing pattern related to pain as evidenced by changes is respiratory rate or pattern from baseline, tachypnea and changes in depth of respiration NURSING PLAN After 8 hours of nursing intervention, The respiratory rate of the patient will be 1220 cpm, Demonstrate an effective respiratory rate, depth, and pattern and will be able to communicate well. INTERVENTION Independent: Established rapport RATIONALE EVALUATION

Rapport is important to gain patient s cooperation and reduce anxiety. Baseline data is important to help determine patients current health status and evaluate efficacy of nursing interventions rendered. An upright position promotes expansion

After 8 hours of nursing intervention GOAL WAS MET

Obtained vital signs

Placed patient in a semi-fowler position

Elevate Head on Bed As appropriate

Promotes physiological and psychological ease of inspiration to assist client in taking control of the situation.

Encourage slower/deeper respirations, use of pursed-lip technique, and so on Maintain calm attitude while dealing with client Dependent: Administer analgesic as needed

to limit level of anxiety.

To decrease respiration effort due to pain