Nursing Diagnosis Rationale Goal of Care Nursing Intervention Rationale Evaluation

Ineffective breathing The lung contains gas, After 1 hour of nursing Independent:
pattern related to blood, thin alveolar interventions, the client GOAL MET.
decreased lung walls and support will: 1. Identify etiology or Understanding the
expansion structures. The alveolar precipitating factors. cause is necessary for Within 1 hour of
wall contains elastic 1. Establish a normal choice of therapeutic nursing care, the
and collagen fibers; and effective breathing measures. patient stated
these form a three- pattern within client’s acceptable dyspnea.
dimensional basket- normal range. 2. Monitor vital signs. Monitoring the vital
like structure that signs is necessary to “Mas nakakaginhawa
allows the lung to evaluate the degree of na ako hin maupay
inflate in all directions. compromise. kesa kanina.”
These fibers are In addition, the patient
capable of stretching 3. Assess lung sounds, Respiratory rate less participated in
when a pulling force is respiratory rate and than 12 or more than treatment regimen.
exerted on them from effort and the use of 24 or use of accessory Vital signs are within
outside of the body or accessory muscles. muscles indicate normal range.
when they inflate from distress. Diminished
within. The elastic lung sounds indicate
recoil helps return the possible poor air
lungs to their resting movement and
volume. If air or impaired gas exchange.
increased amounts of
serous fluid, blood, or 4. Evaluate respiratory Respiratory distress
pus accumulate in the function, noting rapid and changes in vital
thoracic space, it may or shallow respirations, signs occur as a result
hinder adequate lung dyspnea, reports of “air of physiologic stress
expansion and causes hunger,” and changes and pain, or may
the pleural membranes in vital signs. indicate development
(essential for diffusion of shock due to
of gases) to compress hypoxia or
thus respiratory hemorrhage.
difficulties follow.
5. Observe skin and Cyanosis indicates
Sources: mucous membranes for poor oxygenation. Oral
signs of cyanosis. mucous membrane
Medical-Surgical cyanosis indicates
Nursing 8th Edition by serious hypoxia.
Black and Hawks
6. Encourage adequate Helps limit oxygen
Understanding rest and limit activities needs and
Medical-Surgical within client’s level of consumption.
Nursing 3rd Edition by tolerance. Promote a