Nursing Care Plan

Topics: Perfusion, Nursing care plan, Cheyne-Stokes respiration Pages: 10 (3227 words) Published: December 28, 2012
Nursing Diagnosis # 1
Ineffective breathing pattern related to decreased oxygen saturation, poor tissue perfusion, obesity, decreased air entry to bases of both lungs, gout and arthritic pain, decreased cardiac output, disease process of COPD, and stress as evidenced by shortness of breath, BMI > 30 abnormal breathing patterns (rapid, shallow breathing), abnormal skin colour (slightly purplish), excessive diaphoresis, nasal flaring and use of accessory muscles, statement of joint pain, oxygen saturations of 85-95% 2L NP, immobility 95% of the day, and adventitious sounds throughout lungs (crackles) secondary to CHF, hypertension, pain caused by gout and arthritis, and obesity Goals

1)The patient will demonstrate effective breathing patterns to ensure sufficient oxygen is being obtained throughout the body within two days 2)The patient will be able to state what a healthy, balanced meal is in two weeks’ time 3)The patient will be able to maintain an oxygen saturation > 93% R/A by the end of the week 4)The patient will verbalize when he is in pain and would like pain medications by the end of the shift 5)The patient will sit on the side of the bed by the end of the day and by the end of the week ambulating as tolerated 6)Patients diaphoresis will be decreased daily with respiratory and physical exercises 7)Patient will be able to state the importance of weight management and demonstrate exercises to increase success in lowering BMI in 6 weeks 8)Patient will incorporate his family and/or support systems into his care to obtain and meet health goals Nursing interventions

1)Teach the patient how to breathe effectively with slow, deep, abdominal breathing and incorporate pursed lip breathing to ensure there is sufficient oxygen being perfused to the body. Rationale: Incorporating slow deep abdominal breaths allows the lungs to fill to capacity increasing air entry to the lung bases and with the pursed lip exhaling allows the oxygen a longer time to diffuse through the alveoli, which will increase oxygen saturations throughout the body. 2)teaching the patient how to incorporate the Canada food guide into his lifestyle and meal planning Rationale: teaching the patient how to use the Canada food guide will ensure the patient is receiving the amount of nutrient he needs when planning healthy meals to make lifestyle choices 3)Administering oxygen as ordered by the physician will ensure the patient is getting adequate oxygenation and perfusion to all cells until the patient is able to effectively breathe without the need of intervention Rationale: administering oxygen allows the body to get adequate tissue perfusion throughout the body which will also improve the patient’s skin pigmentation. 4)Educate the patient on the importance of reporting pain when it starts using a 0-10 pain scale Rationale: If the patient states that there is pain it allows for intervention with pharmacological means such a Tylenol # 3’s in this patient’s case. 5)Administration of pharmacological interventions when the patient states pain greater than a 3/10 on a 0-10 pain scale Rationale: administering an NSAID or an analgesic will decrease swelling or decrease the pain that is felt by the patient which will decrease any anxiety related to the pain which will allow the patient to breathe more freely 6)Refer the patient to physio for a consult to see where the patient is with mobility Rationale: This will allow further interventions with mobility 7)Assisting the patient to sitting on the side of the bed and eventually with ambulation around the room. Rationale: by assisting the patient it will get him moving and will increase the patient’s confidence in himself which may increase the chances that he will continue to want to ambulate in small amounts 8)Incorporating deep breathing or the use of an incentive spirometer and physical movements (stretches, etc.) to increase stamina Rationale: by increasing the patients stamina will...
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