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Assessment

The patient was experiencing dyspnea, tachypnea, crackles in both lung fields, and an RR of 28. The nursing diagnosis was ineffective breathing pattern and decreased lung volume capacity. Short term goals were for the patient to demonstrate coping behaviors and methods to improve breathing within 3 hours. Long term goals were for the patient to apply techniques to improve breathing and be free of respiratory distress within 1-2 days. Planned nursing interventions included monitoring vitals, assessing breath sounds, elevating the head, providing a relaxing environment, supplemental oxygen, relaxation techniques, and prescribed medications.

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Ejoy Rayos Adawag
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53 views2 pages

Assessment

The patient was experiencing dyspnea, tachypnea, crackles in both lung fields, and an RR of 28. The nursing diagnosis was ineffective breathing pattern and decreased lung volume capacity. Short term goals were for the patient to demonstrate coping behaviors and methods to improve breathing within 3 hours. Long term goals were for the patient to apply techniques to improve breathing and be free of respiratory distress within 1-2 days. Planned nursing interventions included monitoring vitals, assessing breath sounds, elevating the head, providing a relaxing environment, supplemental oxygen, relaxation techniques, and prescribed medications.

Uploaded by

Ejoy Rayos Adawag
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Assessment Subjective: Dyspnea Objectives: The patient manifested the following: Tachypnea Presence of crackles on both lung fields

upon auscultation use of accessory muscles RR of 28 The patient maymanifest the following: Cyanosis Orthopnea Diaphoresis

Nursing Diagnosis Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea

Planning Short Term:After 3 hours of nursing interventions the patient will demonstrate appropriate coping behaviors and methods to improve breathing pattern. Long term: After 1 to 2 days of nursing interventions, the patient would be ableto applytechniques that would improve breathing pattern and be free from signs and symptoms of respiratory distress.

Nursing Interventions - Establish rapportMonitor and record vital signs - Assess breath sounds, respiratory rate, depth and rhythm - Elevate head of the pt. - Provide relaxing environment - Administer supplemental oxygen as ordered -Assisst client in the use of relaxation technique - Administer prescribed medications as ordered

Rationale - To gain pt/ SOs trust and cooperation- To obtain baseline data - To note for respiratory abnormalities that may indicate early respiratory compromise and hypoxia - To promote lung expansion - To promote adequate rest periods to limit fatigue - To maximize oxygen available for cellular uptake -To provide relief of causative factors - For the

Expected Outcome Short Term:The patient shall have demonstrated appropriate coping behaviors and methods to improve breathing pattern. Long term: The patient shall have applied techniques that improved breathing pattern and be free from signs and symptoms of respiratory distress AEB respiratory rate within normal range, absence of cyanosis, effective breathing and minimal use of accessory muscles during breathing.

-Maximize respiratory effort with good posture and effective use if accessory

pharmacological management of the patients condition

muscles. -Encourage adequate rest periods between activities

-To promote wellness - to limit fatigue

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