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COLLEGE OF NURSINGSILLIMAN UNIVERSITY, DUMAGUTE CITY

NURSING CARE PLAN

CUES/EVIDENCES NURSINGDIAGNOSIS

OBJECTIVES INTERVENTIONS RATIONALE EVALU

Objective

y Shortness of breath

y Dyspneay

Tachypneay Cyanosisy Nasal flaringy Respiratory

depth changesirregularly

y Altered chest excursion

y Use of

accessorymuscles

RR=cpm, shallow,irregular and labored

IneffectiveBreathing Patternr/t prolongedgeneral anesthesiasecondary togastrectomy

After the 16 hour nursing carethe client will manifest physiologic signs of effectivebreathing pattern as evidencedby:

-verbalization of relief of SOB-diminished or absence of the ff signs and symptoms:

y Dyspneay Tachypneay Cyanosisy Nasal flaringy Shallow depth

breathingy Altered chest

excursiony Use of accessory

muscles-RR within normal range (12-20 cpm deep, regular andeffortless)

Independent

y Assess respiratory rateand depth by listening tolung sounds.

y Monitor breathingpatterns

y Use pulse oximetry tomonitor oxygensaturation and pulserate.

y Monitor ABGs asappropriate; notechanges.

y Monitor for changes inorientation, increasedrestlessness, anxiety, andair hunger.

y Respiratory rate and rhythmchanges are early warningsigns of impending respiratorydifficulties.

y Specific breathing patternsmay indicate an underlyingdisease process or dysfunction.

y Pulse oximetry is a useful toolto detect changes inoxygenation early on; however,for CO 2 levels, end tidalCO2 monitoring or arterialblood gases (ABGs) wouldneed to be obtained.

y Increasing PaCO2 anddecreasing PaO2 are signs of respiratory failure. As thepatient begins to fail, therespiratory rate decreases andPaCO2 begins to rise.

y Restlessness is an early sign of hypoxia.

At the end of ounursing care, climanifest physioof effective breapattern as eviden

-expressed comfrelief of SOB-diminished signs and sympt

Dyspn Tachy Cyano Nasal

Altereexcurs Use o

musclRR= cpmregular and effo

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y Assess skin color,temperature, capillary

refill; note central versusperipheral cyanosis.

y Position patient withproper body alignment for optimal breathingpattern.

y Ensure that oxygendelivery system isapplied to the patient.

y An oxygen saturation of 90% or greater shouldbe maintained.

Encourage sustained deepbreaths by:

y Using demonstration(emphasizing slowinhalation, holding endinspiration for a fewseconds, and passiveexhalation)

y Using incentivespirometer (place closefor convenient patient use)

y Asking patient to yawn

y Use pain management asappropriate.

y Monitoring detects changesearly.

y If not contraindicated, a sittingposition allows for good lungexcursion and chest expansion.

y The appropriate amount of oxygen is continuouslydelivered so that the patient does not desaturate.

y This provides for adequateoxygenation.

y These simple techniquespromotes deep inspiration.

y This allows for pain relief andthe ability to deep breathe.

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