![]() ![]() ![]() The wheezing and rhonchi in the anterior lungs were diminished. Post albuterol administration, vital signs were respiratory rate 16, pulse 78, and O2 sat 90% on room air. Patient was placed in tripod position at edge of bed and encouraged to use pursed-lip breathing and Huff coughing. Oxygen applied via nasal cannula at 1 L/min albuterol nebulizer and scheduled medications were administered. Scattered wheezing and rhonchi present anteriorly, with diminished breath sounds in the posterior lower lobes. Upon awakening, the patient reported a dyspnea level of a “4” and stated, “I’m feeling short of breath and tired today.” Vital signs were respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. You enter the following documentation note in the patient record. Smith to rest after eating breakfast, but encourage a walk in the hallway later that morning. He rates his current level of dyspnea as a “2” and states, “I feel less short of breath but I am still tired.” The SMART outcome was “met.” You encourage Mr. The wheezing and rhonchi in the anterior lungs have diminished. Smith and find the following: respiratory rate 16, pulse 78, and O2 sat 90% with NC at 1 L/min. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%.Īmbulation will help to mobilize the secretions so they can be removed.Īfter administering medications and applying the oxygen, you reassess Mr. Resting frequently decreases oxygen demand.ĩ. ![]() Schedule care activities to allow frequent rest periods. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly patients who have increased risk for developing fluid overload.Ĩ. Encourage fluids (2000 mL/24 hours) and monitor intake and output.Īdditional fluids will help thin secretions so they can more easily be coughed up. Huff coughing will help clear secretions.ħ. Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Smith to use pursed-lip breathing and Huff coughing. Fluticasone is an inhaled corticosteroid that will reduce inflammation in the airways.Ħ.Tiotropium is a long-acting bronchodilator.Albuterol is a rapid-acting bronchodilator that will open the airways and improve the amount of oxygen reaching the alveoli with each inhalation.Administer scheduled and PRN medications:Įach medication has a different mechanism of action that will assist Mr. Oxygen therapy will reduce the work of breathing.ĥ. ![]() Apply oxygen via nasal cannula, starting at 1 L/min and titrate until 90% pulse oximetry reading is obtained per standing order. Positioning will assist in maximum expansion of lungs.Ĥ. Place patient in high Fowler’s or tripod position as needed to reduce feelings of dyspnea. Decreasing the patient’s anxiety levels will help decrease the feeling of dyspnea.ģ. Implement NIC Interventions for Anxiety Reduction (as outlined in Box 8.3).ĭyspnea creates feelings of anxiety. Implement NIC interventions for Respiratory Monitoring NIC (as outlined in Box 8.3 ).Įstablish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented.Ģ. Planned Nursing Interventions with Rationale: Interventionsġ. Smith’s reported level of dyspnea will be within his stated desired range of 1-2 by the end of the shift. Overall Goal: The patient will have adequate movement of air into and out of the lungs. Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea and use of accessory muscles to breathe and patient stating, “I’m feeling short of breath and tired today.”
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