Cues Nursing Goals/Objectives Intervention Rationale Evaluation

Diagnosis

Subjective: Ineffective breathing After 8 hours of nursing Independent: Goal met. After 8
pattern related to intervention, the client hours of nursing
will establish an  Auscultate chest  To evaluate intervention, the client
effective respiratory presence/character was able to establish
pattern. of breath an effective
sound/secretions respiratory pattern

 Assess for  That may restrict

Objective: concomitant limit respiratory
pain/discomfort effect
 Dyspnea
 Nasal flaring  Maintain calm  To limit level of
 Capillary refill (4 attitude while anxiety
seconds) dealing with client
 Cyanosis
 Encourage position  To provide relieve
of comfort of causative factors

Dependent:

 Administer oxygen  For management of

at lowest underlying
concentration pulmonary
indicated and condition,
prescribed respiratory distress,
respiratory or cyanosis
medications

 Medicate with  To promote deeper

analgesic, as respiration
 appropriate

Collaborative:

 Assists with  To provide relief of

bronchoscopy or causative agents
chest tube insertion
as indicated