Ineffective Breathing Pattern 2uq6u

ASSESSMENT

SUBJECTIVE: Stated: “Nahihirapan akog huminga at saka kinakapos ako sa paghinga.”

OBJECTIVE: Dyspnea Observed physical discomfort use of accessory muscle noted oxygen in use via nasal cannula, 2-

NURSING DIAGNOSIS

SCIENTIFIC EXPLANATION

INEFFECTIVE BREATHING PATTERN RELATED TO TRACHEOBRONCHIAL OBSTRUCTIO N SECONDARY TO PLEURAL EFFUSION AS EVIDENCED BY DYSPNEA

Tracheobronchial obstruction  Amounts of fluid are drained from the pleural cavity  fluid pressure in the pleural cavity  Atelectasis in the affected side of the lung  Impaired cardiac filling/inflamed pleural membranes (intensified on

PLANNING

LONG TERM OUTCOME: After 2 days of nursing intervention, the client will be able to:

INTERVENTION

RATIONALE

INDEPENDENT: Assess respiratory rate and depth by listening to lung sounds.

Establish a normal/effective respiratory pattern AEB absence of s/s of hypoxia, normal skin color.

Note muscles used for breathing(sternocleidomastoid, diaphragmatic) and retractions/flaring of nostrils

SHORT TERM OUTCOME:

position client with proper body alignment(semifowler’s position)

After 4 hours of nursing intervention, the client will be able

Ensure that oxygen delivery

Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties. these signify an increase in work of breathing

EVALUATION

LONG TERM OUTCOME ACHIEVED: After 2 days of nursing intervention, the client will be able to: Establish a normal/effective respiratory pattern AEB absence of s/s of hypoxia, normal skin color.

This is for good SHORT TERM lung excursion OUTCOME and chest ACHIEVED: expansion After 4 hours of nursing intervention, the

3L/min mucus/secreti on production

inspiration) 

to:

verbalize awareness of Dyspnea, difficulty in causative factors breathing, altered chest excursion, demonstrate respiratory depth appropriate changes coping behaviors like proper breathing and Reference: Medical coughing Surgical Nursing:Brunner 11th edition, p.652

system is applied to the patient, the appropriate amount of oxygen is delivered pace and schedule activities providing adequate rest periods Encourage sustained deep breaths by emphasizing slow inhalation, holding end inspiration) Teach client appropriate deep breathing and coughing techniques

COLLABORATIVE: ister oxygen at lowest concentration indicated

this provides adequate oxygenation to prevent patient from desaturation

client will be able to: verbalize awareness of causative factors

demonstrate appropriate coping behaviors This prevents like proper dyspnea resulting breathing and from fatigue coughing these promote deep inspiration

these facilitate adequate clearance of secretions

For management of underlying pulmonary condition and respiratory

distress. Refer the client to a dietician and or groups.

--.for proper counseling and intake of caloric needs.