NURSING CARE PLAN 4

1.            Ineffective breathing pattern related to severe pain as evidenced by dyspnea.

Goal: Patient will breathed normally without using oxygen support.

No.	Nursing Intervention	Rationale
1.	Assess patient’s respiratory status.	To plan further treatment
2.	Monitor vital signs especially rate of respiration. Normal respiratory rate is 12 to 20 breaths/min in the adult.	To assess any abnormal changes
3.	Monitor breathing pattern and chest movement either shallow or deep.	To detect changes early
4.	Note abdominal breathing, use of accessory muscles, nasal flaring or lethargy.	The uses of external accessory muscle is indicator for dyspnea
5.	Monitor patient’s oxygen saturation and blood gases. Normal oxygen saturation is 90% to 100% while partial pressure of oxygen is 80% to 100%.	To know the level of oxygen in the blood
6.	Position the patient in an upright or Semi-Fowler’s position.	An upright position facilitated lung expansion.
7.	Administer oxygen as ordered.	Supplemental oxygen helps reduce hypoxemia and relieve respiratory distress
8.	Encourage the patient to take deep breaths.	To increase the expansion of the lung

Evaluation: Patient was able to breathe normally on his own.