NURSING CARE PLAN

SSESSMENT NURSING SCIENTIFIC OBJECTIVES INTERVENTIONS RATIONALE EXPECTED OUTCOME

DIAGNOSIS EXPLANATION
Subjective cues: Ineffective Inspiration and/or Short-term Objective: Independent: Independent: Short-term
∅ breathing pattern expiration that does not After 2-3 hours of nursing Objective:
related to provide adequate intervention, patient will be able 1. Establish rapport with 1. To gain patients trust • Client shall verbalize
Objective cues: hyperventilation as ventilation. to: patient and cooperation understanding and
- Respiration rate evidenced by • Verbalize understanding 2. Assess and record 2. The average rate of demonstrate proper deep
of 29 bpm respiration rate of It is defined as a state in and demonstrate proper respiratory rate and respiration for adults is breathing technique to
29 bpm which one's breathing rate, deep breathing technique depth at least every 4 10 to 20 breaths per facilitate proper oxygenation
depth, timing, rhythm, or to facilitate proper oxygen hours. minute. It is important to to alleviate hyperventilation
pattern has changed. The to alleviate take action when there
body is most likely not hyperventilation is an alteration in the
getting enough oxygen to • Patient will have pattern of breathing to • Patient shall have
the cells when the breathing respiratory rate within detect early signs of respiratory rate within
pattern is ineffective. normal limits respiratory compromise. normal limits
Respiratory failure may be 3. Assess ABG levels, 3. This monitors
correlated with variations in according to facility oxygenation and
respiratory rate, abdominal, policy. ventilation status.
and thoracic pattern. 4. Assess client’s 4. Affects ability to
awareness and manage own airway
In many cases, changes in Long-term cognition and cooperate with
Long-term Objective:
breathing patterns may also Objective: interventions such as
be due to heart failure, controlling breathing Patient will have normal
hypoxia, airway After 2-3 days of nursing and managing breathing pattern
obstruction, diaphragm intervention, patient will be free secretions
paralysis, infection, of abnormal breathing pattern 5. Note clients reports 5. Client may report
neuromuscular damage, and perceptions of arrange of symptoms
trauma, or surgery leading breathing ease (SOB with speaking)
to musculoskeletal damage and demonstrate a
and/or pain, cognitive wide range of signs
impairment, and anxiety. (e.g., tachypnea,
gasping, wheezing,
and coughing)
6. Observe 6. May see use of
Hyperventilation is not a characteristics of accessory muscles
disease. Instead, it is a breathing pattern for breathing, sternal
symptom of another retractions, nasal
condition or the result of flaring, or pursed
emotional distress such as breathing
the one being manifested 7. Direct client in 7. To assist client in
by our patient in the case breathing efforts as “takin control” of the
scenario. While a good needed. Encourage situation, especially
balance of breathing in slower and deeper when condition is
oxygen and breathing out respiration and use of associated with
carbon dioxide results in the pursed lip anxiety and air
healthy breathing. When technique hunger
you hyperventilate, you Teaching technique
disturb this equilibrium by 8. Emphasize the 8. To maximize
exhaling more than you importance of good respiratory effort
inhale. This produces a fast posture and effective
decrease in carbon dioxide use of accessory
levels in the body. Low muscles
carbon dioxide levels lead
to narrowing of the blood Dependent: Dependent:
vessels that supply blood 1. Medication as ordered 1. Assist patient in
resulting in increase in decreasing
respiration rate to be able to respiration rate
compensate for the
decreased of oxygen due to
hyperventilation.

Doenges, M. E.,
Moorhouse, M. F., & Murr,
A. C. (2019). Nurse's
pocket guide: Diagnoses,
prioritized interventions,
and rationales.
Philadelphia, PA: F.A.
Davis Company.
CASE SCENARIO 3:

A 38-year-old female patient came to the clinic for a routine check-up. She reports a 1-year history of weakness
and emotional instability. She also mentions a tingling sensation in her feet. She also has noticed weight loss since she
began having the symptoms. Upon examination, her heartbeat was normal; however, she was tachycardic but at rest she
was a tachypneic.

1. Past Medical History: history of gastric bypass surgery for obesity 4 years ago
2. Social History: no tobacco or illicit drug use
3. Physical Examination: pallor, red tongue, loss of vibratory sense in lower extremities, disorientation, muscle
weakness
4. Vital Signs: T 37.1 ⁰C; PR 110 bpm; RR 29 bpm; BP 110/60 mmHg; weight 58 kg

Laboratory Results:

• Hgb: 7.5 g/dL

• RBC: 3.2 cells/mm3
• HCT: 23 %
• Platelet Count: 450,000/mm3
• WBC: 5,400 cells/mm3/Differential is normal
• Serum Iron: 80 mcg/dL
• Ferritin: 150 mg/mL
• Serum B12: 78 ng/mL
• Total Iron Binding Capacity (TIBC): 300 mcg/dL
• Total Iron Binding Capacity (TIBC): 300 mcg/dL