PLANNING

NURSING IMPLEMENTATIO
ASSESSMENT OBJECTIVE OF EVALUATION
DIAGNOSIS INTERVENTION RATIONALE N
CARE
Subjective Cues: At the end of the 8 At the end of the 8
hours nursing hours nursing
 “ya pone kunele  Assess and  The average  Assessed and
intervention the intervention the
oxygen del Tuesday, record rate of recorded the
Ineffective client will be able client was able to:
kabar ya kita sila respiratory respiration for respiratory
breathing pattern to:
olet del Wednesday rate and adults is 10 to rate and  The patient
related to
kabar pag-ka Friday  Patient depth at 20 breaths per depth at least maintained
underlying
ya pone sila olet maintains an least every 4 minute. It is every 4 an efficient
condition
asta ara ya” effective hours. important to hours. breathing
(enlargement of
breathing take action pattern, as
the abdomen) as
pattern, as when there is an shown by
evidence by
Objective Cues: evidenced by alteration in calm
more than the
relaxed breathing breathing at
 Hyperventilation normal rate,  Observed the
breathing at patterns to normal rate
 Abnormal rate, rhythm and depth patient’s
normal rate detect early and depth
rhythm, depth in in breathing. breathing
and depth signs of and the lack
breathing and absence compromise on patterns. of dyspnea.
Vital Signs: of dyspnea. the respiratory  The patient's
system. respiration
RR- 53 bpm  Patient’s
rate has
respiratory
 Observe   Assessed for decreased in
rate remains
breathing Unusual breathing the use of comparison
within
patterns. patterns may imply an accessory mu to the prior
established
underlying disease scle. result.
limits.
process or dysfunction.  Patient was
 Patient Cheyne-Stokes able to
indicates, respiration signifies indicate,
either bilateral dysfunction in either
verbally or the deep cerebral or  Monitored verbally or
through diencephalon related to for through
behavior, brain injury or diaphragmati behavior,
feeling metabolic c muscle feeling
 comfortable abnormalities. fatigue or comfortable
when Apneusis and ataxic weakness when
breathing. breathing are related to (paradoxical breathing.
the failure of the motion).  Patient or the
 Patient or
respiratory centers in significant
the
the pons and other
significant
medulla. Rates and reported that
other of the
depths of breathing the patient is
patient will  Utilized the
patterns include: well rested.
report pulse
 Patient
feeling  Apnea oximetry to
performed
rested each Temporary check oxygen
diaphragmati
day. cessation of saturation
c pursed-lip
breathing, and pulse
 Patient breathing.
especially rate.
performs  Patient
during sleep
diaphragmat demonstrated
ic pursed-lip  Apneusis maximum
breathing. Deep, gasping lung
inspiration with  Placed the expansion
 Patient
a pause at full patient with with adequate
demonstrate
inspiration proper body ventilation.
s maximum
followed by a alignment for
lung
brief, maximum
expansion
insufficient breathing
with
release pattern.
adequate
ventilation.  Ataxic patterns
Complete
irregularity of  Maintained a
breathing with clear airway.
irregular pauses
and increasing
periods of apnea
 Biot’s
respiration
Groups of
 quick, shallow
inspirations
followed by
regular or   Encouraged
irregular periods frequent rest
of apnea (10 to periods and
60 seconds). teach the
patient/
 Bradypnea
significant
Respirations fall
other to pace
below 12
activity.
breaths per
minute,
depending on
the age of the  Encouraged
patient. small
frequent
 Cheyne-Stokes meals.
respiration
Progressively
deeper and  Helped the
sometimes patient with
faster breathing, ADLs, as
followed by a necessary.
gradual
decrease that
results in apnea.
The pattern
repeats, with  Availed a fan
each cycle in the room.
usually taking
30 seconds to 2
minutes.  Educated pat
ient or
 Eupnea
significant
Normal, good,
other on
unlabored
proper
 ventilation, breathing,
sometimes coughing,
known as quiet and splinting
breathing or methods.
resting,
respiratory rate
 Teached the
 Hyperventilati
significant
on
other of the
Increased rate
patient about
and depth of
pursed-lip
breathing
breathing,
 Kussmaul’s abdominal
respirations breathing,
Deep performing
respirations relaxation
with fast, techniques,
normal, or slow performing
rate associated relaxation
with severe techniques,
metabolic taking
acidosis, prescribed
particularly medications
diabetic (ensuring the
ketoacidosis accuracy of
(DKA) but dose and
also kidney fail frequency
ure and
monitoring
 Tachypnea
adverse
Rapid, shallow
effects),
breathing, with
scheduling
more than 24
activities to
breaths per
avoid fatigue,
minute
and provide
for rest
  Assess for periods.
the use of
 Work of
accessory m
breathing
uscle.
increases
greatly as lung
compliance
decreases
 Monitor for
diaphragma
tic muscle  Paradoxical
fatigue or movement of
weakness the abdomen
(paradoxica (an inward
l motion). versus outward
movement
during
inspiration) is
indicative of
respiratory
muscle fatigue
and weakness.
 Utilize pulse
oximetry to  Pulse oximetry
check is a helpful tool
oxygen to detect
saturation alterations in
and pulse oxygenation
rate. initially; but, for
CO2 levels,
end-tidal CO2
monitoring or
arterial blood
gases (ABGs)
would require
 Place obtaining.
patient with
proper  A sitting
body position permits
alignment maximum lung
for excursion and
maximum chest expansion.
breathing
pattern.

 Maintain a
clear
airway.  Encouraging the
patient to
mobilize their
own secretions
via effective
coughing
facilitates
adequate
clearance of
  Encourage
secretions.
frequent
rest periods
 Extra activity
and teach
can worsen
the patient
shortness of
to pace
breath. Ensure
activity.
the patient rests
between
strenuous
 Encourage activities.
small
frequent  This prevents
meals. crowding of the
diaphragm.
 Help the
 patient with
ADLs, as
 This conserves
necessary.
energy and
avoids
overexertion
 Avail a fan
and fatigue.
in the room.
 Moving air can
decrease
feelings of air
 Educate pat hunger.
ient or
significant
other on  These allow
proper sufficient
breathing, mobilization of
coughing, secretions.
and
splinting
methods.

 Teach the
significant
other of the
patient  These measures
about allow the
pursed-lip patient to
breathing, participate in
abdominal maintaining
breathing, health status
performing and improve
relaxation ventilation.
techniques,
performing
 relaxation
techniques,
taking
prescribed
medications
(ensuring
the
accuracy of
dose and
frequency
and
monitoring
adverse
effects),
scheduling
activities to
avoid
fatigue, and
provide for
rest periods.

DEPENDENT
 Provide
respiratory
medications
 Beta-adrenergic
and oxygen,
agonist
per doctor’s
medications
orders.
relax airway
smooth muscles
and cause
bronchodilation
to open air
passages.