Nurse's Pocket Guide

ineffective BREATHING PATTERN
• Review environmental factors (e.g., exposure to dust, high
pollen counts, severe weather, perfumes, animal dander,
household chemicals, fumes, second-hand smoke; insufficient
home support for safe care, etc.) that may require avoidance/modification
of lifestyle or environment to limit
impact on client’s breathing.
• Advise regular medical evaluation with primary care provider
to determine effectiveness of current therapeutic regimen
and to promote general well-being.
• Instruct in proper use and safety concerns for home oxygen
therapy, as indicated.
• Make referral to support groups/contact with individuals who
have encountered similar problems.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Relevant history of problem.
• Respiratory pattern, breath sounds, use of accessory muscles.
• Laboratory values.
• Use of respiratory aids/supports, ventilator settings, and so
forth.
PLANNING
• Plan of care/interventions and who is involved in the
planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching, actions performed, and
treatment regimen.
• Mastery of skills, level of independence.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs, including appropriate referrals and action
taken, available resources.
• Specific referrals provided.
SAMPLE NURSING OUTCOMES & INTERVENTIONS
CLASSIFICATIONS (NOC/NIC)
NOC—Respiratory Status: Ventilation
NIC—Ventilation Assistances
Information in brackets added by the authors to clarify and enhance
the use of nursing diagnoses.
144 Cultural Collaborative Community/Home Care