Problem or Cues

Objectives:
Alteration
in depths
of
breathing
Dyspnea
Tachypnea
O2 in use
via nasal
canula 23L/ min

Nursing
Diagnosis
ineffective
breathing
pattern related
to decreased lung
compliance
(dispensability)
associated with pleural
effusion and
accumulation of fluid in
the pulmonary
interstitium and alveoli

Objectives

Interventions

Rationale

Evaluation

After 30 minutes
of nursing
intervention the
client will
experience
adequate
respiratory
function as
evidenced by
normal rate,
rhythm, and
depth of
respirations

Assess
respiratory rate
and depth by
listening to lung
sounds.

RR and rhythm
changes are
early sign of
impending
respiratory
difficulties.

Position the
patient with
proper body
alignment.

This is good for

lungs and chest
expansion.

Ensure that O2
delivery system
is applied to the
patient and the
appropriate
amount of O2 is
delivered.

Provides
adequate
oxygenation to
prevent patient
from
desaturation

After 30 minutes
of nursing
intervention the
client was
experienced
adequate
respiratory
function as
evidenced by
normal rate,
rhythm, and
depth of
respirations

Administered O2
in lowest
concentration
indicated

administer the
medication if
ordered:
diuretics

For management
of underlying
pulmonary and
respiratory

to decrease fluid
accumulation in
the lungs

Problem or Cues
Alteration
in depths
of
breathing
Dyspnea
Tachypnea
O2 in use
via nasal
canula 23L/ min

Nursing
Diagnosis
Ineffective
breathing
pattern related
to diminished
lung/chest wall
expansion
associated with
pleural effusion

Objectives

Interventions

Rationale

Evaluation

After 30 minutes
of nursing
intervention the
client will
experience
adequate
respiratory
function as
evidenced by
normal rate,
rhythm, and
depth of
respirations

Monitor vital
signs, respiratory
status, and pulse
oximetry.

Frequent
monitoring of
vital signs,
oxygen
saturation, and
respiratory
efforts can alert
the nurse and
doctor to a
change in
condition.

After 30 minutes
of nursing
intervention the
client was
experienced
adequate
respiratory
function as
evidenced by
normal rate,
rhythm, and
depth of
respirations

Listen to breath
sounds q shift or
more often if
needed

Ambulate patient
as tolerated with
doctors order
three times daily.

Listen to breath
sounds with each
assessment
throughout the
day, or with any
change of
condition
Ambulation can
help break up
and move

Encourage
frequent rest
periods and
teach patient to
pace activity.

secretions that
block the
airways.

Over activity can

worsen shortness
of breath. Ensure
the patient rests
between
strenuous
activities

Administered O2
in lowest
concentration
indicated

administer the
medication if
ordered:
diuretics

For management
of underlying
pulmonary and
respiratory

to decrease fluid
accumulation in
the lungs