Assessment Diagnosis Planning Intervention Rationale Evaluation

Suazo, Trisha Mae S.
3BSN-A 10/7/20
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective: Ineffective After 8 hours of 1. Assess and record Useful in evaluating the After 8 hours of nursing
“I have emphysema breathing pattern nursing intervention: respiratory rate, depth. degree of respiratory intervention:
for 25 years and I related to -patient will report Note the use of distress or chronicity of -patient’s vital signs is
also smoke. I find it ineffective improvement of accessory muscles, the disease process within normal range and
difficult to breathe inspiration and breathing pattern. pursed-lip breathing, demonstrates proper
most of the time that expiration -patient will maintain and inability to speak or breathing technique
goes with chest pain evidenced by a respiratory rate converse.
and I have cough for increased RR, within normal limits. -patient reports reduced
a long time now. ” crackles upon 2. Monitor O2 saturation Pulse oximetry reading episodes of dyspnea
As verbalized by auscultation. and titrate oxygen to of 87% below may during activity
John. maintain Sp02 from indicate the need for
Impaired gas -patient will 88% to 92%. oxygen administration -patient participates in
Objective: exchange related demonstrate improved while a pulse oximetry treatment regimen
-weak looking to altered O2 ventilation and reading of 92% or higher within the level of
-sputum production supply evidenced adequate oxygenation may require oxygen ability/situation
-dyspnea by dyspnea. of tissues and be free titration.
-barrel chest of symptoms of -patient identifies the
-crackles upon respiratory distress. 3. Monitor vital signs Tachycardia, hazards of cigarette
auscultation -patient will and cardiac rhythm. dysrhythmias, and smoking
participate in changes in BP can reflect
VS taken as ff: treatment regimen the effect of systemic -patient identifies
BP: 130/90 within the level of hypoxemia on cardiac resources for smoking
PR: 110 bpm ability/situation. function. cessation
RR: 24 bpm
O2 SAT: 94% 4. Maintain a patent Remove secretions that -pt minimizes or
PAIN SCALE:8/10 Activity -patient will report airway, suctioning of obstructs the airway. eliminates exposures.
intolerance related reduced episodes of secretions may be done
to ineffective dyspnea during an as ordered.
breathing patterns activity.
evidenced by
dyspnea, increased 5. Provide respiratory Aid in relieving the
RR. support. Oxygen patient from dyspnea.
inhalation is given as
ordered.
6. Instruct how to splint Promotes physiological
the chest wall with a ease of maximal
pillow for comfort inspiration.
during coughing and
elevation of head over
the body as appropriate.
7. Teach pt the ff
activities to improve
breathing pattern:
-Inspiratory muscle This may help improve

training the breathing pattern.
-Diaphragmatic Diaphragmatic breathing

breathing reduces respiratory rate,
increases alveolar
ventilation, and
sometimes helps expel as
much air as possible
during expiration.
-Pursed lip breathing Pursed lip breathing

helps slow expiration,
prevents collapse of
small airways, and
control the rate and depth
of respiration.
8. Assess patient’s Manifestation of

respiratory status every respiratory distress
2 to 4 hours as indicated include shortness of
and notify any abnormal breath, tachypnea,
findings. changes in mental status
and the use of accessory
muscles.
9. Auscultate breath Decreased breath sounds,

sounds every 2 to 4 crackles, wheezes, and
hours as indicated. rhonchi can be observed
and must be reported
promptly for immediate
treatment.
10. Evaluate the level of During severe, acute or

activity tolerance. refractory respiratory
Provide a calm, quiet distress, the patient may
environment. Limit be totally unable to
patient’s activity or perform basic self-care
encourage bed or chair activities because of
rest during the acute hypoxemia and dyspnea.
phase. Have patient Rest interspersed with
resume activity care activities remains an
gradually and increase important part of the
as individually tolerated. treatment regimen. An
exercise program is
aimed at increasing
endurance and strength
without causing severe
dyspnea and can enhance
a sense of well-being.
11. Maintain prescribed

activity levels. Helps in building
tolerance and minimizing
episodes of dyspnea.
12. Teach and assist the

patient with active ROM Aids in building stamina
exercises. and avoid complications
of limited mobility.
13. Provide at least 90
minutes of undisturbed Allotment of undisturbed
rest in between rest reduces demand for
activities. oxygen and allows
adequate physiologic
recovery.
14. Instruct patient with
energy conservation Working at an even pace
techniques, such as: These techniques reduce
-Placing frequently used oxygen consumption,
items within easy reach allowing a more
-Sitting to do tasks prolonged activity.
-Frequent position
changes
15. Teach the patient on

exercises that enhances These techniques prolong
breathing capacity such exhalation period which
as diaphragmatic and can decrease retention of
purse-lip breathing. carbon dioxide.
16. Patient education is

vital to long-term Provide information to
management. Teach the the patient and family
patient about the disease about medications and
and its implications for equipment.
lifestyle changes, such
as avoidance of cigarette
smoke and other
irritants, activity
alterations, and any
necessary occupational
changes

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Suazo, Trisha Mae S.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

-Inspiratory muscle This may help improve

-Diaphragmatic Diaphragmatic breathing

-Pursed lip breathing Pursed lip breathing

8. Assess patient’s Manifestation of

9. Auscultate breath Decreased breath sounds,

10. Evaluate the level of During severe, acute or

11. Maintain prescribed

12. Teach and assist the

15. Teach the patient on

16. Patient education is

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