Actual NCP - ineffective breathing PDF

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Summary

ineffective breathing...

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ASSESSMENT Subjective:  “she told me that I cant breath” stated by the mother Objectives:  BP: 90/60 mmHg  HR: 115 bpm  RR: 33 cpm  Temp: 37.8 °C  weak looking  malaise  poor appetite  noted “shortness of breath” Nursing diagnosis:  Ineffective breathing pattern related to Community acquired pneumonia

EXPLANATION OF THE PROBLEM It is considered the state in which the rate, depth, timing, and rhythm, or the pattern of breathing is altered. When the breathing pattern is ineffective, the body is most likely not getting enough oxygen to the cells. Increased capillary permeability and vasodilation to provide adequate perfusion, oxygen, and nutrients to tissue and cells. Imbalance of inflammatory response and organ shutting down due to physiologic progression of infecting including lungs. This may cause ineffective breathing pattern.

OBJECTIVES LTO: Within 24-48 hours of effective nursing interventions, the patient - Will be able to have a normal breathing pattern and presence of breath STO: Within 30 minutes-1 hour of effective nursing interventions, the patient will be able to: - Achieved maximum lung expansion with adequate ventilation. - Return O2 saturation to normal - Demonstrate appropriate breathing technique.

INTERVENTION Dx:  Assessed and record O2 saturation and respiratory rate, depth, and quality.

RATIONALE

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To detect early signs of respiratory distress.

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Monitored for use of accessory muscles

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To be able to identify increased in work of breathing by retraction

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Observed for nasal flaring

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Breathing may increased as lung compliance

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Supplemental oxygen helps reduce hypoxemia and relieve respiratory distress

Tx:  Administered oxygen as ordered

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Positioned in semi fowler

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to maximize lung expansion

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Assisted patient with ADL

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to conserve energy and avoid overexertion and fatigue

Edx:  Instructed proper breathing techniques

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measure to allow patient to participate in maintain health status and improve ventilation

Encourage to have rest periods in between daily activities

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this prevent fatigue and reduces oxygen demand

Educated regarding the importance of compliance to given medication.

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for patient to gain more understanding about the treatment being given

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EVALUATION LTO:(GOAL MET) After 24-48 hrs of effective nursing interventions, the patient had: - will achieved normal respiratory rate with normal breathing pattern

STO:(GOAL MET) After 30 minutes-1 hour of effective nursing interventions, the patient had: achieved maximum lung expansion with normal O2 saturation and able to perform properly the breathing technique...