Ineffective Breathing Pattern

ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

(Subjective & Objective) (Dependent, Independent &

Collaborative)

SUBJECTIVE: Altered Breathing Altered Breathing Pattern SHORT TERM: INDEPENDENT SHORT TERM:
Pattern related to is considered the state in
“Magkutas man ko usahay After 1 hours of holistic Assessed and monitored An alteration in the After 1 hours of holistic
increased production of which the rate, depth, patient’s respiratory rate and pattern of breathing
ma’am,” as verbalized by mucous secretions in timing, and rhythm, or the nursing intervention, the nursing intervention, the
breathe sounds. Noted helps detect early
the patient. the lungs due to pattern of breathing is patient will be able to: patient was able to:
adventitious breath sounds signs of respiratory
OBJECTIVE: prolonged stay in bed altered. Thick secretions 1) Demonstrate such as wheezing compromise 3) Demonstrate
retained in the lungs may appropriate appropriate breathing
Monitored oxygen saturation Measuring oxygen
● Weakness noted be correlated with breathing exercises exercises
saturation will
● Use of accessory immobility thus results 2) Demonstrate proper determine the need for 4) Demonstrate proper
muscles during change in respiratory manipulation of oxygen for manipulation of
inspiration status. supplementation
treatment device treatment device
observed
● Nasal flaring After 2 hours of nursing After 2 hours of nursing
noted interventions, the patient Monitored heart rate and Heart rate increases interventions, the patient
rhythm as respiratory rate
● Wheezing heard will be able to maintain was able to maintain an
increases
upon auscultation an effective breathing effective breathing pattern,
● Respiratory rate pattern, as evidenced as evidenced by:
of 26cpm by: Elevated head These measures
● PR = 132 bpm promote maximal ● relaxed breathing
Hinkle, J. L., & Cheever, K. H.
● 02 Sat = 93% (2014b). Brunner & Suddarth's ● relaxed Encouraged frequent position inspiration and ● respiration rate of
Textbook of Medical-Surgical Nursing
breathing changes enhance 20cpm from 26 cpm
(13th ed.). Two commerce square,
2001 Market St., Philadelphia: ● normal RR expectoration of ● absence of dyspnea
Lippincott Williams & Wilkins within the range secretions to improve
ventilation
of 16-20 cpm
Immobility and
from 26 cpm. dehydration may
● absence of
dyspnea cause decrease
ventilation and
increase stasis of
secretions

Instruct patient to do proper Deep breathing

breathing exercises after exercises increase
proper demonstration oxygen intake and
alleviates dyspnea

Positioned in high-fowler’s Promotes lung

position expansion

Promoted chest physiotherapy Promotes drainage of

secretions
DEPENDENT:

Administer medications as Aids in reduction of

ordered bronchospasms and
mobilization of
secretions
COLLABORATIVE:

Refer to physical therapy or For evaluation and

respiratory therapy further treatment
Deficient Fluid Volume
INTERVENTIONS
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING (Dependent, RATIONALE EVALUATION
(Subjective & Independent &
Objective) Collaborative)

SUBJECTIVE: Deficient fluid volume is a SHORT TERM INDEPENDENT: SHORT TERM

Deficient Fluid Volume state or condition where
No verbal cues related to the fluid output exceeds After 8 hours of holistic Monitored vital signs: Note Aids in evaluating After 8 hours of holistic
Venous compression the fluid intake. It happens nursing interventions, the any signs of hypotension, degree of fluid deficit,
nursing interventions, the
OBJECTIVE: secondary to when water and patient will be able to tachycardia, tachypnea, and effectiveness of fluid
goal was partially met. The
o Sunken eyeballs Complete Mechanical electrolytes are lost as manifest: fever. replacement therapy,client was able to manifest
o Dry and cracked lips Bowel Obstruction they exist in normal body and response to moist lips good skin turgor
o Poor skin turgor fluids. In mechanical 1. Moist lips medication and with vital signs of:
o Capillary Time Refill: bowel obstruction, when 2. Good skin turgor TEMP: 37.2
more than 2 seconds . the bowel is distended it 3. Vital signs within Observed skin and mucous Indicates excessive PR: 104 bpm (slightly
o With 2 colostomy bags: will cause the obstruction normal range membrane dryness and fluid loss and elevated)
a) Fistula – at midline GI secretions accumulate turgor. resultant dehydration. RR: 20 cpm
between T8 and T12 in large amounts; LONG TERM BP: 90/60 mmHg (still the
b) Colostomy (2015) – consequently results in Encouraged use of lip balm Aids and moisturizes same
at right upper quadrant deprivation of the After 5 days of noble cracked and dry lips
absorptive activity of nursing interventions, the
o With #57 TPN at right intestine beyond the patient will be able to Instructed to eat the These will help LONG TERM
upper thigh obstruction and also demonstrate improved following: foods rich in improve the patient’s
damage in fluid and fluid balance as protein, such as meat and laboratory values After 5 days of noble nursing
Taken Feb. 1, 2019 electrolyte exchange in evidenced by: egg; green leafy vegetables, interventions, the goal was
o Decreased: the wall of the obstructed and banana not met since there’s no
serum albumin: 2.78 g/dL and distended gut. 1) Weight gain evident weight gain and
(3.5 – 5.3 g/dl) 2) Normal value of the Weighed weekly Indicator of overall laboratory studies values
following laboratory fluid and nutritional remained low.
Total Protein: 65.60 g/L Vincenzo Neri (September 21st 2016).
Management of Intestinal Obstruction,
studies: status.
(66-83 ) Actual Problems of Emergency o CBC
Abdominal Surgery, Dmitry
Victorovich Garbuzenko, IntechOpen,
o Electrolytes Monitored accurate intake Reflects hydration
Taken Feb. 2, 2019 DOI: 10.5772/63156. Available from: o Serum albumin and output status: Urine output
o Decreased: https://www.intechopen.com/books/
actual-problems-of-emergency-
o Total protein may be diminished
Na+ : 120.50mmoL/L abdominal-surgery/management-of- because of
(135-145) intestinal-obstruction hypovolemia
K+: 3.2 mmoL/L (3.50-
 5.50) Changed position frequently, Edematous tissue
Cl: 84.50 mmol/L (98- provided frequent skin care, with compromised
108) and maintained dry, wrinkle- circulation is prone to
free bedding. skin breakdown.
Taken Feb. 13, 2019
o Decreased: DEPENDENT:
RBC – 2.12 (4.5)
Hgb - 61.00 (140-175) Provided Total Parenteral Replenishes and
Hct- 19.800% (41.5-50.4) Nutrition maintains circulating
volume and
o Vital Signs: electrolyte balance.
T: 38.7C COLLABORATIVE:
P: 132 bpm
R: 26 cpm Monitored laboratory
BP: 90/60 studies:
o CBC Provides hydration
o Electrolytes status and organ
o Serum albumin function.
o Total protein
Imbalanced Nutrition: Less than Body Requirements
INTERVENTIONS
ASSESSMENT NURSING DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING (Dependent, RATIONALE EVALUATION
(Subjective & Independent &
Objective) Collaborative)
SHORT TERM INDEPENDENT: SHORT TERM
SUBJECTIVE:
“Ika #57 nana nako nga Imbalanced Nutrition: Happens when water and After 30 minutes of Obtained a thorough Identifies deficiencies After 30 minutes of holistic
TPN ma’am wala gyud Less than Body electrolytes are lost as holistic nursing health nutritional assessment. and needs to aid in nursing health teaching, the
Requirements they exist in normal body teaching, the patient and choice of patient and SO was able to:
gihapun ko nabalik sa
related to fluids. In complete SO will be able to: interventions.
sakto nga panglawas ug impaired absorption of mechanical bowel - Ask questions
timbang” verbalized by the nutrients and obstruction, when the - Verbalize Auscultated bowel sound Return of intestinal related with nutrition
patient. electrolytes bowel is distended it will understanding function indicates to healing process
secondary to cause the obstruction GI with significance readiness to resume and general health
OBJECTIVE: Mechanical Bowel secretions accumulate in of nutrition to oral intake
o Decrease Obstruction large amounts; healing process LONG TERM
subcutaneous tissues consequently results in and general Weighed as indicated Monitors
o With Total Parenteral deprivation of the health effectiveness of After 4 weeks of holistic
absorptive activity of dietary plan nursing interventions, the
Nutrition (TPN) at right
intestine beyond the goal was not met. The
upper thigh obstruction and also LONG TERM Encouraged oral hygiene A clean mouth patient was able to:
damage in fluid and every after meal. enhances appetite
o Loss of weight: electrolyte exchange in After 4 weeks of holistic - Verbalized that he is
Prior admission: 62kg the wall of the obstructed nursing interventions, the willing to follow the
During and distended gut. patient will be able to: Encouraged to verbalize Hesitation to eat treatment regimen.
feelings concerning diet. maybe the result of
admission:49kg
- Demonstrate fear that food will
Upon assessment on progressive cause exacerbation of
the 1st day of duty: weight gain symptoms.
38kg Vincenzo Neri (September 21st 2016). toward goal with
Management of Intestinal Obstruction,
Height: 5’6’’ Actual Problems of Emergency normalization of Promoted proper positioning Elevating the head of
BMI: 13.5 (18.5
Abdominal Surgery, Dmitry
Victorovich Garbuzenko, IntechOpen,
laboratory values the bed 30 degrees
normal) DOI: 10.5772/63156. Available from: and be free of aids in swallowing
https://www.intechopen.com/books/
actual-problems-of-emergency-
signs of and reduces risk for
abdominal-surgery/management-of- malnutrition. DEPENDENT: aspiration with eating
Taken Feb. 1, 2019 intestinal-obstruction
o Decreased: - Provided Total Parenteral This provides
serum albumin: 2.78 g/dL Nutrition with amino acid essential nutrients for
(3.5 – 5.3 g/dl) patients who are
unable to maintain
Total Protein: 65.60 g/L nutrition resulted from
(66-83 ) impaired absorption
from bowel
Taken Feb. 2, 2019 obstruction.
o Decreased: COLLABORATIVE:
Na+ : 120.50mmoL/L
(135-145) - Instructed SO to ask from This provides proper
K+: 3.2 mmoL/L (3.50- the dietary department the nutrition to the
5.50) list of foods appropriate for patient.
Cl: 84.50 mmol/L (98- the patient.
108)

- Monitor laboratory studies: Provides information

o Vital Signs upon o Albumin about nutritional
assessment: o Total Protein deficits and
T: 38.7C effectiveness of
P: 132 bpm therapy.
R: 26 cpm
BP: 90/60