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Respiratory Comp: Nursing Diagnosis

The patient presents with difficulty breathing and is experiencing Kussmaul respirations due to metabolic acidosis. Over the course of 8 hours of nursing interventions, the patient will demonstrate improved breathing patterns by performing pursed-lip breathing and diaphragmatic breathing exercises. After 3 days, the patient is expected to have decreased respiratory distress and verbalize understanding of their condition. The nursing care plan involves establishing rapport, monitoring vital signs, auscultating breath sounds, encouraging deep breathing exercises, diet modifications, and allowing for rest.

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Maria Francheska Osi
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811 views

Respiratory Comp: Nursing Diagnosis

The patient presents with difficulty breathing and is experiencing Kussmaul respirations due to metabolic acidosis. Over the course of 8 hours of nursing interventions, the patient will demonstrate improved breathing patterns by performing pursed-lip breathing and diaphragmatic breathing exercises. After 3 days, the patient is expected to have decreased respiratory distress and verbalize understanding of their condition. The nursing care plan involves establishing rapport, monitoring vital signs, auscultating breath sounds, encouraging deep breathing exercises, diet modifications, and allowing for rest.

Uploaded by

Maria Francheska Osi
Copyright
© © All Rights Reserved
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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SUMAGUE, Maria Francheska O.

BSN 4 – NDA

Assessment Scientific Planning Interventions Rationale Evaluation


Explanation
Subjective: Respiratory comp STO: 1. Establish rapport. 1. To gain pt.’s trust. STO:
“Di po ako nakkaahinga ng ensation for this After 8 hours of 2. assess pt.’s condition 2. To obtain baseline Patient is not able to
maayos, parang hinahabol acidotic condition nursing interventions, 3. VS monitor and data demonstrate pursed-lip
ko ang hininga ko.” results in Patient will record 3. Serve to track breathing and diaphragmatic
Kussmaul demonstrate pursed-lip 4. Auscultate breath important changes breathing.
Objective: respirations, ie, breathing and sounds and assess 4. to check for the
 wheezing upon rapid, diaphragmatic airway pattern presence of LTO:
inspiration and shallow breathing  breathing. 5. Elevate head of the adventitious breath Patient now manifest signs of
expiration (sigh breathing) bed and change sounds decreased respiratory effort
 dyspnea that, as the LTO: position of the pt. 5. To minimize AEB absence of dyspnea
 coughing, sputum is acidosis grows After 3 days of nursing every 2 hours. difficulty in
yellow and sticky more severe, interventions, Patient 6. Encourage deep breathing Patient now verbalizes
 tachypnea, prolonged becomes slower, will manifest signs of breathing and 6. To maximize effort understanding of causative
expiration deeper, and decreased respiratory coughing exercises. for expectoration. factors and demonstrate
 tachycardia labored (air effort AEB absence of 7. Demonstrate 7. To decrease air behaviors that would improve
 chest tightness hunger). dyspnea diaphragmatic and trapping and for breathing pattern
pursed-lip breathing. efficient breathing.
 suprasternal retraction
Patient will verbalize 8. Encourage increase 8. To prevent fatigue.
 restlessness
understanding of in fluid intake 9. To prevent
 anxiety causative factors and 9. Encourage situations that will
 cyanosis demonstrate behaviors opportunities for rest aggravate the
 loss of consciousness that would improve and limit physical condition
breathing pattern activities.
10. Reinforce low salt, 10. To mobilize
NURSING DIAGNOSIS: low fat diet as secretions.
Ineffective breathing pattern ordered.
r/t related to a decreased
ability to breathe

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