nursing diagnosis?? please help!

[Starfish1]

does this make any sense to anyone? please let me know- just a general case study on a post op patient- if you are using the green medical-surgical nuring seventh edition

chapter 20

cast study at end of chapter

a nursing diagnosis

ineffective breathing related to anesthesia as evidenced by low O2 levels

interventions

monitor rate, rhythmn depth and effort of respirations to determine need for additional resp support

outcomes

respiratory rate is between 16-20 breaths per minute

thank you

[sdjohnso]

Here's how I perceive it:

The patient cannot breathe effectively due to the effects that anesthesia has on them. They came to this conclusion by taking the pt's SpO2, and seeing it was

The interventions are just watching the characteristics of the breaths and making sure there's nothing more abnormal.

Something to think about is, sometimes pt's will naturally have low sats, and it may not be strange for them to be hanging out around the 90-93% range. I've seen a "normal" sat at 88-89%.

[Daytonite, BSN, RN]

the definition of ineffective breathing pattern is inspiration and/or expiration that does not provide adequate ventilation. (page 26, nanda-i nursing diagnoses: definitions & classification 2007-2008) this has to do with the patient's physical breathing efforts. low o2 levels are evidence of hypoxia and the nursing diagnosis of impaired gas exchange. a low o2 may end up being a result of poor inspiration and expiration, but it is not a defining characteristic of it: ineffective breathing pattern i would discuss this idea of a low o2 being evidence of poor ventilation with your instructors. i say it is evidence of hypoxia.