study

ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

1. dyspnea
2. coughing
3. cyanosis
4. tachypnea
Ineffective breathing pattern related to increased work of breathing.
At the end of 8 hours of duty, the patient will be able to know how to deal with the situation and lessen the respiratory distress being experienced.
Assess respiratory status when the patient is calm. A minimum of every 2-4 hours or more often as indicated for an increasing or decreasing respiratory rate and episodes of apnea.











Administer humidified oxygen via mask, nasal cannula, hood, or tent


Assess pulse oximetry on room air and compare to reading when child is on oxygen.

Note patient’s response to ordered medications.



Position head of the bed up or place child in position of comfort.
Changes in breathing pattern may occur quickly as the patient’s energy reserves are depleted. Assessment and monitoring baseline reveal rate and quality of air exchange. Frequent assessment and monitoring provides objective evidence of changes in the quality of respiratory effort, enabling prompt and effective intervention.


Humidified oxygen loosens secretions, helps maintain oxygenation status and eases respiratory distress.

Comparison of pulse oximetry readings provides information about improvement status.

Medications act systematically to improve oxygenation and decrease inflammation.

Position facilitates improved aeration and promotes decrease in anxiety and energy expenditures.
At the end of 8 hours of duty, the patient displayed understanding about her condition and learned how to lessen the distress that she experienced.