POC Ineffective Breathing Pattern
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ASSESSMENT* (DATA BASE sorted & grouped for EACH nursing diagnosis) ANALYSIS* (NURSING DIAGNOSIS/ES) PLAN (CLIENT GOAL/ OUTCOME for EACH nursing diagnosis) IMPLEMENTATION (NURSING ACTIONS, including teaching) RATIONALE FOR EACH NURSING ACTION EVALUATION OF CLIENT GOALS O Crackles bilaterally O Mild cough O Nasal flaring O Retractions O RR 32 S Mother states that child slept well on an upright position. S Mother states that child was breathing Analysis: The infant dx is influenza with crackles bilaterally, nasal flaring and retractions having an ineffective breathing pattern. Ineffective Breathing Pattern r/t acute infection AEB alterations in depth of breathing, nasal flaring, retractions and cough. STG: During shift the child’s respiratory rate will remain within acceptable range (25-30) LTG: After 4 hours of care the child will not evidence an increase in cough, nasal flaring or retractions. Assess (3 items) 1. Assess respiratory rate, depth, and ease of respiration. 2. Assess color of tongue, oral mucosa, and skin for signs of cyanosis 3. Assess use of accessory muscles, nasal flaring, and retractions Action (3 items) 1. Auscultate breath sounds, noting decreased or absent sounds, crackles, or wheezes. 2. Position the client in an upright position. 3. Administer oxygen as per doctor’s orders Teaching (3items) 1. Teach the caregiver of the child about dosage, actions, Assess. 1. When respiratory rate exceeds normal range, along with other physiological measures, a study demonstrated that physiological alteration existed. 2. Cyanosis of tongue and oral mucosa is central cyanosis and represents medical emergency. 3. These symptoms signal increasing respiratory difficulty and increasing hypoxia. Action: 1. These abnormal lung sounds can indicate a respiratory pathology associated with an altered breathing pattern. 2. An upright position facilitates lung 1. RR within acceptable range 29 STG met. 2. 4 hours after initial care the child is not coughing, no nasal flaring or retractions noted. LTG met.
description
Pediatrics Nursing Care PlanIneffective Breathing Pattern
Transcript of POC Ineffective Breathing Pattern
ASSESSMENT*(DATA BASE sorted
& grouped for EACH nursing diagnosis)
ANALYSIS*(NURSING
DIAGNOSIS/ES)
PLAN(CLIENT GOAL/
OUTCOME for EACH nursing diagnosis)
IMPLEMENTATION(NURSING
ACTIONS, including teaching)
RATIONALE FOR EACH
NURSING ACTION
EVALUATIONOF CLIENT GOALS
OCrackles bilaterally
OMild cough
ONasal flaring
ORetractions
ORR 32
SMother states that child slept well on an upright position.
SMother states that child was breathing faster during nap time.
Analysis: The infant dx is influenza with crackles bilaterally, nasal flaring and retractions having an ineffective breathing pattern.
Ineffective Breathing Pattern r/t acute infection AEB alterations in depth of breathing, nasal flaring, retractions and cough.
STG:During shift the child’s respiratory rate will remain within acceptable range (25-30)
LTG:After 4 hours of care the child will not evidence an increase in cough, nasal flaring or retractions.
Assess (3 items)1. Assess respiratory rate, depth, and ease of respiration.2. Assess color of tongue, oral mucosa, and skin for signs of cyanosis3. Assess use of accessory muscles, nasal flaring, and retractionsAction (3 items)1. Auscultate breath sounds, noting decreased or absent sounds, crackles, or wheezes.2. Position the client in an upright position.3. Administer oxygen as per doctor’s ordersTeaching (3items)1. Teach the caregiver of the child about dosage, actions, and side effects of medications.2. Teach the caregiver of the child to identify and avoid specific factor that exacerbate ineffective breathing pattern, such as exposure to other sources of air pollution.3. Teach the caregiver of the child to promote the purse-lip and controlled breathing technique to the child.
Assess.1. When respiratory rate exceeds normal range, along with other physiological measures, a study demonstrated that physiological alteration existed.2. Cyanosis of tongue and oral mucosa is central cyanosis and represents medical emergency.3. These symptoms signal increasing respiratory difficulty and increasing hypoxia.Action:1. These abnormal lung sounds can indicate a respiratory pathology associated with an altered breathing pattern.2. An upright position facilitates lung expansion.3. Oxygen administration has been shown to correct hypoxemia, which causes dyspnea.Teaching1. Inhaled steroids and bronchodilators can have undesirable side effects.2. Exposure to exacerbating factor can trigger symptoms and cause a worsening in respiration.3. Purse-lip breathing was effective in decreasing breathlessness and improving respiratory function.
1. RR within acceptable range 29STG met.
2. 4 hours after initial care the child is not coughing, no nasal flaring or retractions noted. LTG met.
