University San Carlos College of Nursing Nursing Care Plan Name of Patient: Age: Sex: Occupation: Status: Religion:

Date of Admission Needs/Nursing Diagnoses/cues >Physiologic Needs >Ineffective Breathing Pattern related to tachypnea >Subjective Cues: --no verbal cues >Objective cues: --dyspnea --nasal flaring --restlessness --hyperventiliting --temp: 36.8 C Initial Complaints: Patients health Profile: Diagnoses:

Scientific Analysis Many clients experiencing compensatory tachypnea because of an inability to meet metabolic demands. This occurs because affective alveoli cannot effectively exchange oxygen and carbon dioxide. Higher respiratory rates can also develops as a result of chest pain and increase body temperature. (medical-surgical

Objectives After 8 hours of nurse-patient interaction, the patient together with the SO will be able to: 1.verbalize understanding about the disease and treatment. 2.demonstrate proper techniques for effective breathing 3.establish a normal /effective respiratory pattern.

Nursing Problems/Interventions To the patient from experiencing tachypnea: 1.provide health teaching

Rationale

-facilitates learning of SO about the disease, prognosis and treatment. -tachypnea, shallow respirations and asymmetric chest movements are frequently present because of discomfort of moving chest wall

2.assess rate /depth of respiration and chest movements.

--pulse rate: 91 bpm Respi rate: 32 cpm --chest assymetrical

nursing black joyce, W.B Saunders 4.cooperate in the Company,Philddelphia, interventions given 6th edition ,volume 2 page 1714) Own analysis: >the patient is having ineffective breathing pattern because of the ineffective exchange of oxygen and carbon dioxide thus as a compensating mechanism, patient exerts more effort in breathing thus having tachypnea.

and fluid in the lungs. 3.elevate head of bed ,change position frequently -Lowers diaphragm, promoting chest expansion, acration lung segments, mobilization and expectoration of secretions. -To limit level of anxiety. -Deep breathing facilitates maximum expansion of the lungs smaller areas, coughing is a natural self cleaning mechanism, assisting the cilia to maintain patient airways. Splinting reduces chest discomfort and upright position

4.maintain calm attitude while dealing with patient and SOS. 5.Assist patient with frequent deepbreathing exerecises.

6. encourage adequate rest periods between activities. 7.Administer drugs as indicated

favors deeper, more forceful cough effort. -To limit fatigue

-aids in reduction of bronchospasm as well as mobilization of secretions treatment of pneumonia. -restlessness, irritation, confusion and somnolence may reflect hypoxemial decreased, cerebral oxygenation. -high fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation

8. assess mental status of the patient.

9. Monitor body temperature as indicated.

10. Observe for adenoration in condition, noting, hypotension copious amts. Of pink bloody sputum, sputum ,pallor, cyanosis

-shock and pulmonary edema are most common cause of death in pneumonia and require immediate medical intervention. (doenges, M, Nursing Care plan, Philadelphia, F. davis Comp , 4th edition pg 132134)