Related to (R/T): The patient has decreased lung compliance. As Evidenced By (AEB): The patient having dyspnea and abnormal ABGs
Desired Patient Outcomes(Goals)
Nursing Interventions
Rationales
Evaluation
STG:
Patient will: Patient will exhibit signs of effective breathing pattern before end of Nursing shift.
1. Nurse will monitor patient’s prescribed oxygen therapy. 2. Nurse will titrate oxygen to keep oxygen greater than ninety percent.
3. Nurse will maintain head of bed at least 30 degrees.
Oxygen toxicity can be a causative agent for respiratory distress.
Levels below ninety percent can indicate inadequate oxygen perfusion.
Elevating head of bed decreases risk of aspiration and facilitates lung expansion.
Patient’s prescribed oxygen has equal to pulse oximetry reading of ninety percent.
Patient’s pulse oximetry readings are greater than ninety percent.
With head of bed elevated patient is breathing better.
LTG:
Patient will: Patient’s ABGs will be within normal baseline limits before discharge from hospital.
4. Nurse will monitor ABGs for changes and trends
5. Nurse will provide relaxation techniques such as imagery, music, and muscle relaxation.
6. Nurse will monitor patient’s ECG changes in cardiac rhythm, dysrhythmias, or conduction defects.
Provides information of acid/base status and oxygenation.
Relaxation techniques ca reduce stress.
Hypoxia can result in life-threatening dysrhythmias that require emergent treatments.
ABGs remain in normal limits for patient.
Patient practiced focusing on a particular object to relax more.
Patient will not show dysrhythmias.
Medication Cards
Brand Name and Generic Name
Normal Dosage Ranges
Contraindications
Levofloxacin (Levaquin)
Premix, ready-to-use injection:
250mg/50ml, 500mg/100ml, 750mg/150ml
NSAIDs may increase the risk of CNS stimulation.
Levaquin may increase the effect of warfarin.
Pharmacotherapeutic Class
Dosage Ordered
Adverse