ASSESSMENT NURSING DX PLANNING INTERVENTION PLANNING EVALUATION Objective: Ineffective After 8 hours of -Auscultate chest -to identity the After 8 hours of difficulty of breathing pattern nursing of evaluate characteristic of nursing breathing as the related to intervention the presence of breathing pattern intervention the patient complained. respiratory muscle client will breathing pattern. patient was able to fatigue. establish a normal establish an Subjective: respiratory pattern -Monitor the vital -Inadequate effective -Dyspnea as evidenced by other sign oxygenation causes respiratory pattern. -Cough sign and symptoms increase of PR -Head ache of hypoxia. - Monitor the rate -To identify the -chest pain and depth type of breathing Vital signs: respiratory pattern. Bp: 150/100mmhg breathing pattern Pr: 88 bpm Rr: 32bpm -Encourage -To provide relieve Temp: 38.2 position comfort of causative factor Body weight: 40kg Heigh: 157 cm -Maintain clam -To limit the level attitude while of anxiety - The nurse on dealing with the duty client administered O2 -Medicate with -To promote Inhalation at analgesic ordered deeper respiration 5lmp via by the physician nasal cannula