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NURSING CARE PLAN

Nursing Problem Cues

Analysis

Goal/Objectives

Nursing Interventions a) Monitor vital signs

Rationale

Evaluation

Nursing Diagnosis: Ineffective Breathing Pattern secondary to community acquired pneumonia as manifested by alterations in depth of breathing. Subjective: Nahihirapan huminga yung baby ko, may halak daw kasi siya. Verbalized by the client s mother. Objective: Use of accessory muscles Labored breathing Restlessness

Ineffective Breathing Pattern is defined as inspiration and/or expiration that do not provide adequate ventilation. A dyspneic person often appears anxious and may experience shortness of breath, a feeling of being unable to get enough air. Dyspnea have many causes, most of which stem from cardiac and respiratory disorders. It is a subjective feeling as it cannot be directly observed but is reported by the client. (Kozier, Vol. 2, 7th Ed., p. 1346)

Goal: After 8 hours of nursing intervention, the client will be able to: y
Reestablish and maintain effective respiratory pattern via oxygen administration thru nasal cannula without the use of accessory muscles and other signs of hypoxia

a) These signs, which should be looked at in total, are checked to monitor functions of the body. The signs reflect changes in function that otherwise might not be observed.

The client was able reestablish


and maintain effective respiratory pattern via oxygen administrati on thru nasal cannula without the use the use of accessory muscles and other signs of hypoxia

b) Assess respiratory rate, rhythm and b) Respiratory rate depth and rhythm changes are early warning signs of impending c) Assess for respiratory pain/discomfort difficulties d) Administer O2 regulated at 2 lpm via nasal cannula as ordered and administer prescribed respiratory medications c) That may restrict respiratory effort d) For management of underlying pulmonary condition and respiratory distress

Measurement: T: 36C RR: 68 cpm PR: 125 bpm

Objectives: After 2 hours of nursing intervention, the client will be able to: y Maintain normal vital signs