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ASSESSMENT*

(DATA BASE sorted


& grouped for EACH
nursing diagnosis)

ANALYSIS*
(NURSING
DIAGNOSIS/ES)

Analysis: The infant dx is


O
with crackles
Crackles bilaterally influenza
bilaterally, nasal flaring

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 faster
during nap time.

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.

PLAN
(CLIENT GOAL/
OUTCOME for EACH
nursing diagnosis)

STG:
During shift the
childs 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.

IMPLEMENTATION
(NURSING
ACTIONS, including
teaching)

RATIONALE FOR
EACH
NURSING
ACTION

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 doctors orders
Teaching (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.
Teaching
1. 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.

EVALUATION
OF CLIENT GOALS

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.