NSG.

DX- Ineffective breathing pattern

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Ineffective breathing Within 8 hrs of nursing  Evaluate  Client responses After 8 hrs minutes of
“My chest hurts real bad, I pattern related to chest intervention, the client will respiratory rate are variable. Rate nursing intervention, the
can’t breath” as verbalized pain as evidenced by be able to: and depth. Note and effort may be client is now able to:
by the patient respiratory rate of 40 cpm. respiratory effort;
 Maintain an increased by pain,  Maintain an
for example,
effective presence of fear, fever, effective
OBJECTIVE: respiratory dyspnea, use of diminished respiratory
-Diaphoretic pattern free of accessory circulating pattern free of
-Tachypneic cyanosis and muscles, and volume due to cyanosis and
-anxious other signs and nasal flaring. blood or fluid other signs and
symptoms of loss, symptoms of
Vital signs: hypoxia , with accumulation of hypoxia, with
[Link]-40 cpm breath sounds secretions, breath sounds
Temp.-37oc equal bilaterally, hypoxia, or equal bilaterally,
Pulse Rate-110 bpm lung fields gastric distention. lung fields
O2 Stat- 95% clearing. Respiratory clearing.
BP- 160/70mmHg  Maintain stable suppression can  Maintain stable
vital signs within occur from long vital signs within
normal range. time period under normal range.
anesthesia or  Goal was met.
heavy use of
opioid analgesics.
Early recognition
and treatment of
abnormal
ventilation may
prevent
complications.
 Paradoxical
movement of the
 Monitor for abdomen (an
diaphragmatic inward versus
muscle fatigue or
outward
weakness
SOURCE/S: (paradoxical movement during
Nursing Care Plan 9th motion). inspiration) is
Edition indicative of
Guidelines for respiratory
Individualizing care muscle fatigue
Across the lifespan
By Doenges, Moorhouse, and weakne
Murr page 105-106  Breath sounds are
often diminished
in lung bases for a
period of time
 Auscultate breath
after surgery
sounds. Note
because of
areas of
normally
diminished or
occurring
absent breath
atelectasis. Loss
sounds.
of active breath
sounds in an area
of previous
ventilation may
reflect collapse of
the lung segment,
especially

 If chest tubes
have recently
been removed.

 Inspect skin and

mucous  Enhances
membranes for respiratory
cyanosis function and lung
expansion.
 Elevate head of Effective in
bed, place in preventing and
upright or semi- resolving
Fowler’s position. pulmonary
Assist with early congestion.
ambulation and
increased time out  Aids in lung re-
of bed. expansion and
maintaining
patency of small
 Encourage client airways,
participation in especially after
and responsibility removal of chest
 for deep breathing tubes.
exercises, use of
adjuncts (e.g.,
incentive
spirometer), and
coughing, as
 Documents
indicated
effectiveness of
therapy or need
for more
 Record response aggressive
to deep-breathing interventions.
exercises or other
respiratory
treatment, noting
breath sounds
 Enhances oxygen
before and after
delivery to the
treatment.
lungs for
circulatory
 Administer uptake, especially
supplemental in presence of
oxygen by reduced and
cannula or mask, altered
as indicated. ventilation.

 Pain medication
helps to reduce
pain felt by the
client.
 Administer pain
medication as  Pulse oximeter
indicated. helps to check the
oxygen saturation
of the patient
 Monitor oxygen whether its
saturation of the increases or
patient using decreases.
pulse oximeter.
[Link]- Impaired physical mobility

ASSESSMENT NURSING PLANNING IMPLEMENTATION RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE: Impaired physical Within 1-2 days of nursing  Review  Identifies After 1-2 days of nursing
mobility related to intervention, the client will : functional ability probable intervention, the client is
fracture as evidenced by  Maintain and reasons for functional now able to:
OBJECTIVE: imbalanced movement. stabilization and impairment. impairments and  Maintain
-Limitation of movement alignment of influences choice stabilization and
-hematoma on right fracture(s). of interventions alignment of
lower extremity  Display callus fracture(s).
-Multiple abrasion formation/beginning  Provide or assist  Helps in  Display callus
-Skin lesion right union at fracture with ROM maintaining formation/beginning
posterior leg site as appropriate. exercises movement and union at fracture
 Demonstrate body functional site as appropriate.
mechanics that alignment of  Demonstrate body
promote stability at joints and mechanics that
the fracture site. extremities promote stability at
the fracture site.
 Lengthy  Goal was met.
 Instruct and assist
convalescence
client with
often follows
exercise program
brain injury, and
and use of
physical
mobility aids.
reconditioning is
Increase activity
an essential part
and participation
of the program.
in self-care as
tolerated.
 Regular turning
SOURCE/S:  Position client to
Nursing Care Plan 9th more normally
avoid skin and
Edition distributes body
tissue pressure
Guidelines for weight and
Individualizing care damage. Turn at
promotes
Across the lifespan regular intervals,
circulation to all
By Doenges, and make small
areas
Moorhouse, Murr page position changes
209-210 between turns  Use of high-top
tennis shoes,
 Maintain “space boots,”
functional body and T-bar
alignment—hips, sheepskin
feet, and hands. devices can help
Monitor for prevent foot
proper placement drop. Hand
of devices and splints are
signs of pressure variable and
from devices. designed to
prevent hand
deformities and
promote optimal
function. Use of
pillows, bedrolls,
and sandbags can
help prevent
abnormal hip
rotation.

 Client is at risk
for development
of deep vein
 Inspect for thrombosis
localized c(DVT) and
tenderness, pulmonary
redness, skin embolus (PE),
warmth, muscle requiring prompt
tension, or ropy medical
veins in calves of evaluation and
legs. Observe for intervention to
sudden dyspnea, prevent serious
tachypnea, fever, complications.
respiratory
distress, and
chest pain.
  The patient might
need special
equipment or
 Evaluate how utensils to
much assistance increase
is needed to independence
perform ADLs. when performing
ADLs. 

 Obstacles in the
room can impede
activities,
 Ensure the safety especially
of the transferring and
environment ambulating. 

 Maintains
comfortable,
safe, and
functional
 Support head and posture,
trunk, arms and andPrevents or
shoulders, and reduces risk of
feet and legs skin breakdown.
when client is in
wheelchair or
recliner. Pad
chair seat with
foam or water-
filled cushion,
and assist client
to shift weight at
frequent intervals
 Useful in
determining
individual needs,
 Refer to physical therapeutic
and occupational activities,
therapists, as and assistive
indicated
 devices.

[Link]- Self care deficit

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE: Self-care deficit related to After a week of nursing  Assess abilities  Aids in After 1-2 days nursing
limitation of movement as intervention, the client and level of anticipating and intervention, the client is
evidenced by inability to will: deficit (0 to 4 planning for now able to:
take care of self. scale) for meeting individual
OBJECTIVE:  Demonstrate  Demonstrate
performing ADLs needs.
- Limitation of techniques and techniques and
movement lifestyle changes lifestyle changes
to meet self-care  Avoid doing  These clients may to meet self-care
needs. things for client become fearful needs.
 Perform self-care that client can do and dependent,  Perform self-care
activities within for self, providing and although activities within
level of own assistance as assistance is level of own
ability. necessary helpful in ability.
preventing
 Identify personal frustration, it is  Identify personal
and community important for and community
resources that can client to do as resources that can
much as possible provide
provide
for self to assistance as
assistance as needed
needed maintain self-
esteem and  Goal was met.
promote recovery.

 Be aware of  May indicate need

impulsive for additional
behavior or interventions and
actions suggestive supervision to
of impaired promote client
judgment. safety.
SOURCE/S:
Nursing Care Plan 9th
Edition
 Clients need
Guidelines for empathy and to
Individualizing care  Maintain a know caregivers
Across the lifespan supportive, firm will be consistent
By Doenges, Moorhouse, attitude. Allow in their assistance.
Murr page 224-225 client sufficient
time to
accomplish tasks

 Enhances sense of
 Provide positive self-worth,
feedback for promotes
efforts and independence, and
accomplishments. encourages client
to continue
endeavors

 Provide self-help  Enables client to

devices, such as manage for self,
button or zipper enhancing
hook, knife-fork independence
combinations, andself-esteem;
long-handled reduces reliance
brushes, on others for
extensions for meeting
picking things up ownneeds; and
from floor, toilet enables client to
riser, leg bag for be more socially
catheter, and active.
shower chair.
Assist and
encourage good
grooming and  Provides for safety
makeup habits. when client is able
to move around
 Position furniture theroom, reducing
against wall, out risk of tripping
of travel path. and falling over
furniture.

 Client may have

 Assess client’s neurogenic
ability to bladder, be
communicate the inattentive, or be
 need to void and unableto
ability to use communicate
urinal or bedpan. needs in acute
Take client to the recovery phase,
bathroom at butusually is able
frequent and to regain
scheduled independent
intervals for control of this
voiding if function as
appropriate recovery
progresses.

 Assists in
development of
retraining program
 Identify previous (independence)and
bowel habits and aids in preventing
reestablish normal constipation and
regimen. Increase impaction (long
bulk in diet. term effects).
Encourage fluid
intake and  May be necessary
increased activity to aid in
establishing
regular bowel
function.

 Administer
suppositories and
stool softeners.