NURSING CARE PLAN

ASSESSMENT
SUBJECTIVE:
Nahihirapan
ako sa
paghinga as
verbalized by
the
patient
OBJECTIVE:
-rapid shallow
Breathing
-O2 Sat 89%

NURSING
DIAGNOSIS
Ineffective
breathing
pattern related
to post-surgical
state as
manifested by
nasal flaring,
pale skin, slight
cyanotic nail
bed, rapid
shallow
breathing, RR
Of 27cpm.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

After 30
minutes of as
nursing
interventions,
the client will
experience
lessened
difficulty of
breathing
manifested by
decreased in RR
from
27cpm to
20cpm with
the absence of
nasal
flaring

INDEPENDENT:
-Elevated head of the
bed for about 30
degrees and ask the
client to assume Dorsal
recumbent.

>Elevation of the bed

facilitates respiratory
function By use of
gravity. It also
decreases pressure on
the abdomen
when assuming the
position

-Encouraged deep
breathing exercises

>Promote chest
Expansion

-Kept environmental
pollution to a
minimum

>Precipitators of that
allergic type of
respiratory reactions
can trigger
bronchospasm

After 30
minutes of
nursing
intervention,
the client
manifested
breathing as
manifested by
decreased in
RR from 27rpm
to 22rpm with
the absence of
nasal
flaring and
presence Of
calm breathing

-Monitored including
respiratory patterns
rate, depth and effort
DEPENDENT:
-Gave supplemental
oxygen via nasal
cannula as ordered

>To evaluate the

condition
of the client

> Helps in giving the

adequate oxygen to
client