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    Ineffective Breathing Pattern

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    Reichelle Perlas
    The nursing diagnosis is ineffective breathing pattern related to tracheobronchial obstruction secondary to pleural effusion as evidenced by dyspnea. Short term goals include the client verbalizing awareness of causative factors and demonstrating appropriate coping behaviors. Long term goals include the client establishing a normal respiratory pattern and achieving absence of hypoxia symptoms. Planned nursing interventions include assessing respiratory status, positioning the client properly, ensuring adequate oxygen delivery, teaching deep breathing techniques, and making appropriate referrals. The rationales provided focus on promoting lung expansion and clearance of secretions to prevent respiratory difficulties and fatigue.

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    Ineffective Breathing Pattern

    Uploaded by

    Reichelle Perlas
    42K views3 pages
    The nursing diagnosis is ineffective breathing pattern related to tracheobronchial obstruction secondary to pleural effusion as evidenced by dyspnea. Short term goals include the client verbalizing awareness of causative factors and demonstrating appropriate coping behaviors. Long term goals include the client establishing a normal respiratory pattern and achieving absence of hypoxia symptoms. Planned nursing interventions include assessing respiratory status, positioning the client properly, ensuring adequate oxygen delivery, teaching deep breathing techniques, and making appropriate referrals. The rationales provided focus on promoting lung expansion and clearance of secretions to prevent respiratory difficulties and fatigue.

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    The nursing diagnosis is ineffective breathing pattern related to tracheobronchial obstruction secondary to pleural effusion as evidenced by dyspnea. Short term goals include the client verbalizing awareness of causative factors and demonstrating appropriate coping behaviors. Long term goals include the client establishing a normal respiratory pattern and achieving absence of hypoxia symptoms. Planned nursing interventions include assessing respiratory status, positioning the client properly, ensuring adequate oxygen delivery, teaching deep breathing techniques, and making appropriate referrals. The rationales provided focus on promoting lung expansion and clearance of secretions to prevent respiratory difficulties and fatigue.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    42K views3 pages

    Ineffective Breathing Pattern

    Uploaded by

    Reichelle Perlas
    The nursing diagnosis is ineffective breathing pattern related to tracheobronchial obstruction secondary to pleural effusion as evidenced by dyspnea. Short term goals include the client verbalizing awareness of causative factors and demonstrating appropriate coping behaviors. Long term goals include the client establishing a normal respiratory pattern and achieving absence of hypoxia symptoms. Planned nursing interventions include assessing respiratory status, positioning the client properly, ensuring adequate oxygen delivery, teaching deep breathing techniques, and making appropriate referrals. The rationales provided focus on promoting lung expansion and clearance of secretions to prevent respiratory difficulties and fatigue.

    Copyright:

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    of 3

    ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

    DIAGNOSIS EXPLANATION

    SUBJECTIVE: INEFFECTIVE Tracheobronchial LONG TERM INDEPENDENT: LONG TERM


    BREATHING obstruction OUTCOME: OUTCOME
    Stated: PATTERN Assess Respiratory ACHIEVED:
    “Nahihirapan RELATED TO  After 2 days of respiratory rate and rate and rhythm
    akog huminga at TRACHEO- nursing depth by listening to changes are After 2 days of
    saka kinakapos Amounts of fluid are intervention, the lung sounds. early warning nursing
    BRONCHIAL
    ako sa drained from the client will be able signs of intervention, the
    OBSTRUCTIO
    paghinga.” pleural cavity to: impending client will be able
    N
    SECONDARY respiratory to:
     Establish a Note muscles
    TO PLEURAL difficulties.
    normal/effective used for Establish a
    OBJECTIVE: EFFUSION AS fluid pressure in breathing(sterno-
    respiratory these signify normal/effective
    EVIDENCED the pleural cavity cleidomastoid,
    pattern AEB an increase in respiratory pattern
    Dyspnea BY DYSPNEA diaphragmatic) and
     absence of s/s of work of breathing AEB absence of
    hypoxia, normal retractions/flaring of s/s of hypoxia,
    Observed
    Atelectasis in the skin color. nostrils normal skin color.
    physical
    discomfort affected side of the
    position client
    lung
    with proper body
    use of SHORT TERM This is for good SHORT TERM
     alignment(semi-
    accessory OUTCOME: lung excursion OUTCOME
    fowler’s position)
    muscle noted and chest ACHIEVED:
    Impaired cardiac
    After 4 hours of expansion
    oxygen in use filling/inflamed
    nursing After 4 hours of
    via nasal pleural membranes
    intervention, the Ensure that nursing
    cannula, 2- client will be able oxygen delivery intervention, the
    (intensified on
    3L/min inspiration) to: system is applied to this provides client will be able
    the patient, the adequate to:
    mucus/secreti  verbalize appropriate amount oxygenation to
    on awareness of of oxygen is prevent patient verbalize
    Dyspnea, difficulty in causative factors awareness of
    delivered from desaturation
    production breathing, altered causative factors
    chest excursion, demonstrate pace and
    respiratory depth appropriate schedule activities demonstrate
    changes coping behaviors providing adequate appropriate
    like proper rest periods coping behaviors
    breathing and This prevents like proper
    dyspnea resulting breathing and
    Reference: Medical coughing Encourage
    from fatigue
    Surgical sustained deep coughing
    Nursing:Brunner 11th breaths by
    these promote
    edition, p.652 emphasizing slow
    deep inspiration
    inhalation, holding
    end inspiration)

    Teach client
    appropriate deep
    breathing and
    coughing
    techniques these facilitate
    adequate
    clearance of
    secretions
    COLLABORATIVE:

    Administer
    oxygen at lowest For
    concentration management of
    indicated underlying
    pulmonary
    condition and
    respiratory
    distress.

    Refer the client to --.for proper


    a dietician and or counseling and
    support groups. intake of caloric
    needs.

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