Nursing Care Plan
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
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
References: Day, R.A., Paul, P., Williams, B., Smeltzer, S.C., & Bare, B. (2010). Textbook of medical/surgical nursing (2nd Cdn. ed.). Philadelphia, PA: Lippincott Williams & Wilkins Potter, P.A., & Perry, A.G. ( 2010). Canadian fundamentals of nursing (4th ed. Rev.). Ross-Kerr, J.C., & Wood, MJ. (Eds., Cdn. ed.). Toronto, ON: Elsevier Mosby 's dictionary of medicine, nursing, & health professionals. 8th ed. 2009. Print. allnurses. (2007). nursing care plans. In allnurses.com. Retrieved November 25, 2012