Stuart, 23 years old,
diagnosed with pneumonia 3 months ago. Because of having not enough money for
hospitalization, his state got worse day by day, until he experience painful
feeling by just breathing. One day his Uncle Bob visits them and saw Stuart having
difficulty of breathing. He accompanied Stuart to the hospital to cure his
suffering. Below is a sample of nursing care plan for Stuart with
ineffective breathing pattern.
ASSESSMENT
Subjective:
"I can't breathe well because of my chest pain," as verbalize by the patient.
Objectives:
I clearly observed to
the patient his/her difficulty of breathing and shortness of breath in response
to his/her altered breath depth and altered chest excursion. As I observe the
timing ratio, there is a prolonged expiration phases. Nasal flaring and
grunting also observe.
Vital signs are taken
and noted as follows: Body temperature is 35.7 degrees Celsius, blood pressure
is 120/80 mmHg, respiratory rate is 23 cycles per minute and pulse rate is 110
beats per minute. Only body temperature is normal, but his/her blood pressure
is considered as pre-hypertension, respiratory rate is above normal also
his/her pulse rate is above normal.
DIAGNOSIS
Ineffective breathing
pattern related to difficulty of breathing as manifested by prolonged
expiration phases than inspiration. (Remember that expiration, also called
exhalation is breathing out while inspiration, also known as inhalation is
breathing in.
PLANNING
After 30 minutes of
nursing intervention, the patient will able to do coping mechanisms to improve
his breathing pattern. (When it comes to difficulty of breathing, nursing
intervention must do in a short period of time).
INTERVENTION
- You must determine if
there is presence of factors and physical conditions that would cause breathing
impairments of Stuart. Start by auscultating his chest to evaluate the types of
breathing pattern. Identify if it is tachypnea, grunting, Cheyne-Stokes, and
other irregular patterns. Cheyne-Stokes breathing is an abnormal pattern of
very shallow breaths to alternating apnea and deep, rapid breathing which is
also called as periodic respiration.
- Ineffective breathing
pattern may also occur when Stuart is experiencing pain located in his chest,
so you must assess for concomitant pain and discomfort that may restrict his
limit respiratory effort. Positioning Stuart may help or prevent this
situation, so encourage him, the patient, to position of comfort of by
elevating the head of the bed or have Stuart to sit up in chair, as appropriate
to promote physiologic ease of maximal inspiration. Note: if immobility is a
factor, you need to reposition the patient at least every two hours.
- Encourage
slower/deeper respirations, use purse lip technique, to assist Stuart in taking
control of the situation and if symptoms persist administer oxygen at lowest concentration
in indicated and prescribed respiratory medication for management of underlying
pulmonary condition. If obstruction of secretions is the cause, suction the airway
as needed to clear the secretions.
- Just remember to
maintain calm attitude while dealing with Stuart to limit his level of anxiety.
Monitor pulse oximetry, as indicated to verify maintenance in oxygen saturation
and maintain emergency equipment in readily accessible location and include age
and size appropriate ET tubes when ventilator support might be needed.
EVALUATION
After 30 minutes of nursing intervention, the patient did the coping mechanisms to improve his breathing pattern.
For more samples of nursing care plan you are free to check it out in our NCP LIST page.
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