Vitals: Temp: 37 °C (98.6 °F), BP: 162/94, Pulse: 92, Respiratory rate: 26 and shallow
Chief complaint: Shortness of breath (SOB) and difficulty breathing
Medical history: Hypertension, hyperlipidemia, and chronic obstructive pulmonary disease (COPD)
|
Nursing Diagnosis |
Subjective Data |
Objective Data |
|---|---|---|
| Impaired gas exchange related to destruction of the alveoli, narrowing of bronchioles, and trapping of air resulting in the loss of lung elasticity | Difficulty breathing and SOB | Crackles and wheezing heard upon auscultation, dyspnea, tachypnea, nasal flaring, use of accessory muscles, late signs of cyanosis (Linton, 2015), and oxygen saturation is 90% on room air |
| Ineffective airway clearance related to bronchoconstriction, increased mucus production | The patient states she has been sleeping in a recliner chair for the past three nights because of difficulty breathing | Wheezing heard upon auscultation, dyspnea, tachypnea, and use of accessory muscles (Linton, 2015) |
| Activity intolerance related to hypoxia (imbalance between oxygen supply and demand) | “I find it difficult to breathe. I can’t catch my breath when I walk a few feet.” — Jane Doe | Late signs of cyanosis, crackles and wheezing heard upon auscultation, and use of accessory muscles (Linton, 2015) |
|
Nursing Interventions |
Rationale |
|---|---|
| Independent Interventions (II): Monitor the patient’s arterial blood gases, oxygen saturation, vital signs, and color and assess for manifestations such as restlessness, anxiety, lethargy, and confusion | This process will help detect potential hypoxemia or hypercapnia (LeMone et al., 2015) |
| Collaborative Interventions (CI): Supervise oxygen (O2) at 2 L/min through nasal cannula as ordered. Instruct the patient and kin not to increase the O2 level | Oxygen therapy is used to treat hypoxia and is prescribed for chronic and acute breathing problems (Rees, 2017). However, a sudden increase in the O2 level can lead to respiratory failure (Linton, 2015) |
| II: Position the patient in an upright or high Fowler’s position (Linton, 2015) | This posture promotes lung ventilation (LeMone et al., 2015) |
| II: Instruct and teach the patient to perform the pursed-lip breathing technique | This technique slows the respiratory rate and reduces air trapping and fatigue (LeMone et al., 2015) |
| II: Demonstrate pursed-lip and diaphragmatic breathing and encourage the patient to practice them periodically | These techniques reduce air trapping and fatigue and help maintain open airways (LeMone et al., 2015) |
| II: Position the patient in an upright or high Fowler’s position | This posture promotes lung ventilation (LeMone et al., 2015) |
| CI: Encourage deep breathing and the use of an incentive spirometer | Using an incentive spirometer prevents complications such as pneumonia and atelectasis (LeMone et al., 2015) |
| CI: Collaborate with a respiratory therapist to teach the patient how to cough effectively | This technique helps open distal alveoli and remove secretions (LeMone et al., 2015) |
| II: Provide emotional support to the patient | This intervention will be therapeutic, make the patient feel comfortable, and help her cope with the diagnosis (Kazanowski, 2017; LeMone et al., 2015) |
|
Expected Outcomes |
|---|
| Arterial blood gases and vital signs will be consistent with patient norms, indicating improvement in gas exchange (Linton, 2015) |
| The pursed-lip breathing technique will reduce dyspnea (Linton, 2015) |
The patient will have open airways. Signs of clear and open airways are normal de
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