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Care Plan Help!!!

Posted

Hello. Once again I am coming for feedback on a care plan. This was a copy and my instructor made one comment on it. (In the red font)

I guess I do not understand what she is really asking.....

Can anyone offer any advice or corrections they think I should make?

Thanks!!!

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[TD]Nursing Diagnosis

Ineffective breathing pattern related to alteration in oxygen supply as evidenced by shortness of breath, oxygen saturation of 87%, and use of accessory muscles while breathing.

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[TD]Expected Outcomes

  1. Patient will establish appropriate breathing pattern evidenced by absence of hypoxia before discharge.

  1. Patient's respiration rate and pulse oximetry will return to normal/acceptable range before discharge.

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[TD]Evaluation

  1. Patient showed no signs of hypoxia or respiratory distress before discharge. (Goal met)
  2. Patient's respiratory rate remained within 17-18 breaths per minute during hospitalization. Her pulse oximetry remained above 92% during hospitalization and once she was weaned off oxygen therapy. (Goal met)

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[TD]Assessment

  1. Patient reported feeling very short of breath last few days and very fatigued.
  2. Patient had oxygen saturation of 87% when arriving at emergency room on room air – patient placed on 2 liters of oxygen.
  3. Patient reported having a very sore throat.
  4. Patient's voice was very hoarse and a dry cough was noticed.
  5. Patient was using accessory muscles during respirations and had nasal flaring present.
  6. Respirations were 28 in emergency room.

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[TD]Nursing Interventions

  1. Monitoring of pulse oximetry and respiratory rate.
  2. Having patient sit in chair or elevate head of bed when patient is in bed.
  3. Administer oxygen therapy as prescribed if needed.
  4. Auscultate chest and lungs.
  5. Encourage use of incentive spirometer every four hours while patient is awake. (Collaborate with respiratory therapy)

Who would you collaborate with one VS? If they gather data indicating abnormals, then what would they do?

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[TD]Rationale

  1. Monitoring pulse oximetry and respiratory rate verifies maintenance and improvement of oxygen saturation.
  2. Elevating the head of bed and having patient in sitting position can promote physiological and psychological ease of maximal inspiration.
  3. Administering oxygen therapy helps with management of any respiratory distress or signs and symptoms of hypoxia.
  4. Auscultating the chest and lungs help to evaluate breath sounds or fluid in lungs.
  5. Using an incentive spirometer can help you practice taking deep breaths, which can help open your airways, prevent fluid or mucus from building up in your lungs, and make it easier for you to breathe.

(Source:

  1. Nursing Pocket Guide in Nursing Central App.
  2. Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 9th Edition (pg 35-36)

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Kuriin, BSN, RN

Specializes in Emergency. Has 4 years experience.

Welp, I see no red font in there. I am color blind, but I swear, I do not see it. Maybe you should bold? And last I checked, you don't need to collaborate with respiratory therapy in teaching proper use of incentive spirometry (and q4hrs while awake is NOT proper use). But, you did mention you would collaborate with respiratory therapy to try and control their breathing.

Whoops! I copied and pasted from my document so the red font did show up.

Her comment was "Who would you collaborate with one VS? If they gather data indicating abnormals, then what would they do?"

Thank you for your comments!! :) This is only my second attempt at a care plan so I am constantly questioning myself!