HELP almost there! but CAREPLAN in the way!

  1. I am burnt out. I'm a first year nursing student trying to achieve a BSN. This was our first clinical semester. IT IS HELL, but the light at the end of the tunnel, 2 weeks left! I can get back to spending time with my son and husband! I can clean my house, finally! I can, dare I say it, have a social life! The one caveat to this glorious relief is that I have paperwork due TOMORROW at noon. I have to do a careplan on a patient I saw for 6 hours yesterday. I messed up big time, I DID not collect enough assessment data to form a coherent and relevant diagnosis, and now I have a gigantic, incurable BRAIN FART! Please help me, even though it's my own damn fault. Don't let "Nurses eat their young" ring true tonight! I need two diagnoses and "exhaustive" interventions (according to the Dean of NSG). I'll have to find the rationales on my own I guess since I can't use internet sources other than Journals. This is my second Careplan, the first one thankfully did very well because I was able to spend a good amount of time on it. That didn't happen this week unfortunately. So bail me out guys, Please! Here's the info:

    75 Y/O male, admited for a LLL Lobectomy, has a Chest tube draining by gravity into a water sealed system. He had a node dissection, and is diagnosed with COPD-no limitations. Complains of SOB while at rest, and more so after ambulating 125 feet. Oxygen sat was at 92%-baseline. So because of that I'm thinking Impaired Gas Exchange related to decreased functional lung tissue secondary to lung lobectomy. Where and how do I fit chest tube care into that diagnosis/careplan? would it be in the objectives? The interventions I have in mind are "Assess/monitor for signs/symptoms of impaired respiratory function" cyanosis, rapid shallow breathing with use of accessory muscles, etc. I'm going to use incentive spirometry, and education for that since he kept use it rapidly and shallowly. I don't have ABG values for him so that's out. Any other ideas? Mobility to improve respiratory function maybe? Ok..

    So then the second one, I am COMPLETELY blank. He has no impairement of mobility, no skin issues, no circulatory issues, no psychosocial/spiritual issues-he spoke to a chaplain, seems calm about his diagnosis and expectations, feels his life so far has been fulfilling, has close family support. I'm just stuck! So please help me if you can guys! I'll appreciate it so much!
  2. Visit irkedoneSN profile page

    About irkedoneSN

    Joined: Apr '09; Posts: 13; Likes: 6


  3. by   FE710
    [FONT=Andale Sans for VST]Reference is at the bottom...Hope this helps!
    [FONT=Andale Sans for VST]Chris
    [FONT=Andale Sans for VST]
    [FONT=Andale Sans for VST]NDx Acute Pain
    [FONT=Thorndale for VST]NANDA: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months[FONT=Thorndale for VST]
    [FONT=Thorndale for VST]Pain is a highly subjective state in which a variety of unpleasant sensations and a wide range of distressing factors may be experienced by the sufferer. Pain may be a symptom of injury or illness. Pain may also arise from emotional, psychological, cultural, or spiritual distress. Pain can be very difficult to explain, because it is unique to the individual. Pain should be accepted as described by the sufferer. Pain assessment can be challenging, especially in older patients in whom cognitive impairment and sensory-perceptual deficits are more common.
    [FONT=Andale Sans for VST]Common Related Factors
    [FONT=Thorndale for VST]Postoperative pain, Cardiovascular pain, Musculoskeletal pain, Obstetrical pain, Pain resulting from medical problems, Pain resulting from diagnostic procedures or medical treatments, Pain resulting from trauma, Pain resulting from emotional, psychological, spiritual, or cultural distress[FONT=Andale Sans for VST]
    [FONT=Andale Sans for VST]Common Expected Outcome
    [FONT=Thorndale for VST]Patient verbalizes adequate relief of pain or ability to cope with incompletely relieved pain.[FONT=Andale Sans for VST]
    [FONT=Andale Sans for VST]Defining Characteristics
    [FONT=Thorndale for VST]Patient reports pain, Guarding behavior, protecting body part, Self-focused, Narrowed focus (e.g., altered time perception, withdrawal from social or physical contact), Relief or distraction behavior (e.g., moaning, crying, pacing, seeking out other people or activities, restlessness), Facial mask of pain, Alteration in muscle tone: listlessness or flaccidness; rigidity or tension, Autonomic responses (e.g., diaphoresis; change in blood pressure [BP], pulse rate; pupillary dilation; change in respiratory rate; pallor; nausea)
    [FONT=Andale Sans for VST]NOC Outcomes[FONT=Thorndale for VST]
    [FONT=Thorndale for VST]Comfort Level; Medication Response; Pain Control
    [FONT=Andale Sans for VST]NIC Interventions[FONT=Thorndale for VST]
    [FONT=Thorndale for VST]Analgesic Administration; Conscious Sedation; Pain Management; Patient-Controlled Analgesia Assistance
    [FONT=Andale Sans for VST]
    [FONT=Andale Sans for VST]
    [FONT=Andale Sans for VST]Ongoing Assessment
    [FONT=Thorndale for VST]Actions/Interventions[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Assess pain characteristics.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Quality (e.g., sharp, burning, shooting)[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Severity (scale of 0 [meaning no pain] to 10, with 10 being the most severe)[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Other methods such as a visual analog scale or descriptive scales can be used to identify extent of pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Location (anatomical description)[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Onset (gradual or sudden)[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Duration (how long; intermittent or continuous)[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Precipitating or relieving factors[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale:[FONT=Thorndale for VST] Assessment of the pain experience is the first step in planning pain management strategies.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain
    [FONT=Thorndale for VST]-Assess for probable cause of pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Different etiological factors respond better to different therapies.[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Assess patient's knowledge of or preference for the array of pain relief strategies available.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Some patients may be unaware of the effectiveness of nonpharmacological methods and may be willing to try them, either with or instead of traditional analgesic medications. Often a combination of therapies (e.g., mild analgesics with distraction or heat) may be most effective.[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Evaluate the patient's response to pain and medications or therapeutics aimed at abolishing or relieving pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]It is important to help patients express as factually as possible (i.e., without the effect of mood, emotion, or anxiety) the effect of pain relief measures. Discrepancies between behavior or appearance and what the patient says about pain relief (or lack of it) may be more a reflection of other methods that the patient is using to cope with than pain relief itself.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Assess to what degree cultural, environmental, intrapersonal, and intrapsychic factors may contribute to pain or pain relief.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]These variables may modify the patient's expression of his or her experience. For example, some cultures openly express feelings, whereas others restrain such expression. However, health care providers should not stereotype any patient response but rather evaluate the unique response of each patient.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST] - [FONT=Thorndale for VST]Evaluate what the pain means to the individual.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]The meaning of the pain will directly influence the patient's response. Some patients, especially the dying, may feel that the "act of suffering" meets a spiritual need.[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Assess the patient's expectations for pain relief.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Some patients may be content to have pain decreased; others will expect complete elimination of pain. This affects their perceptions of the effectiveness of the treatment modality and their willingness to participate in additional treatments.[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Assess the patient's willingness or ability to explore a range of techniques aimed at controlling pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Some patients will feel uncomfortable exploring alternative methods of pain relief. However, patients need to be informed that there are multiple ways to manage pain.[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Assess appropriateness of the patient as a patientcontrolled analgesia (PCA) candidate: no history of substance abuse; no allergy to narcotic analgesics; clear sensorium; cooperative and motivated about use; no history of renal, hepatic, or respiratory disease; manual dexterity; and no history of major psychiatric disorder.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]PCA is the intravenous (IV) infusion of a narcotic (usually morphine or Demerol) through an infusion pump that is controlled by the patient. This allows the patient to manage pain relief within prescribed limits. In the hospice or home setting, a nurse or caregiver may be needed to assist the patient in managing the infusion.
    [FONT=Thorndale for VST]- [FONT=Thorndale for VST]Monitor the patient for changes in general condition that may herald need for change in pain relief method.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]For example, a PCA patient becomes confused and cannot manage PCA, or a successful modality ceases to provide adequate pain relief, as in relaxation breathing.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]If the patient is on PCA, assess the following:[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Pain relief[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]The basal or lockout dose may need to be increased to cover the patient's pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Intactness of IV line[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]If the IV is not patent, the patient will not receive pain medication.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Amount of pain medication the patient is requesting[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]If demands for medication are quite frequent, the patient's dosage may need to be increased. If demands are very low, the patient may require further instruction to properly use PCA.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Possible PCA complications such as excessive sedation, respiratory distress, urinary retention, nausea and vomiting, constipation, and IV site pain, redness, or swelling[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Early assessment of complications prompts intervention.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]If the patient is receiving epidural analgesia, assess the following:[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Pain relief[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Intermittent epidurals require redosing at intervals. Variations in anatomy may result in a "patch effect."[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Numbness, tingling in extremities, a metallic taste in the mouth[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]These symptoms may be indicators of an allergic response to the anesthesia agent or of improper catheter placement.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]* Possible epidural analgesia complications such as excessive sedation, respiratory distress, urinary retention, or catheter migration[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Respiratory depression and intravascular infusion of anesthesia (resulting from catheter migration) can be potentially life threatening.[FONT=Andale Sans for VST]
    [FONT=Andale Sans for VST]Therapeutic Interventions
    [FONT=Thorndale for VST]Actions/Interventions[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Anticipate need for pain relief.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Respond immediately to complaint of pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]In the midst of painful experiences, a patient's perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for the patient's welfare and comfort fosters the development of a trusting relationship.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Eliminate additional stressors or sources of discomfort whenever possible.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Patients may experience an exaggeration in pain or a decreased ability to tolerate painful stimuli if environmental, intrapersonal, or intrapsychic factors are further stressing them.[FONT=Andale Sans for VST]
    - [FONT=Thorndale for VST]Provide rest periods to facilitate comfort, sleep, and relaxation.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]The patient's experiences of pain may become exaggerated as the result of fatigue. In a cyclic fashion, pain may result in fatigue, which may result in exaggerated pain and exhaustion. A quiet environment, a darkened room, and a disconnected phone are all measures geared toward facilitating rest.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Give analgesics as ordered, evaluating effectiveness and observing for any signs and symptoms of untoward effects.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Pain medications are absorbed and metabolized differently by patients, so their effectiveness must be evaluated individually by the patient. Analgesics may cause side effects that range from mild to life threatening.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Notify the physician if interventions are unsuccessful or if the current complaint is a significant change from the patient's past experience of pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]Patients who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent analgesics.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]-Whenever possible, reassure the patient that pain is time limited and that there is more than one approach to easing pain.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST]Rationale: [FONT=Thorndale for VST]When pain is perceived as everlasting and unresolvable, the patient may give up trying to cope with it or experience a sense of hopelessness and loss of control.[FONT=Andale Sans for VST]
    [FONT=Thorndale for VST] (Gulanick, Meg. Nursing Care Plans: Nursing Diagnosis and Intervention, 6th Edition. Mosby, 102006. 2.44).
    [FONT=Thorndale for VST]
  4. by   irkedoneSN
    Thanks for that chris, but I've used acute pain before on a kardex (mini-careplan) and can't use it again. Thanks anyway! Any other thoughts?
  5. by   Daytonite
    a care plan is based on the data that you collect. there may still be some information that you can recall. when was this patient's surgery? this, for all intents and purposes, is a surgical patient. when patient's undergo general anesthesia certain basic care must be undertaken. these are the possible problems and complications of general anesthesia that must be monitored and the patient protected against. you will have been doing some nursing care for them:
    • breathing problems (atelectasis, hypoxia, pneumonia, pulmonary embolism)
    • hypotension (shock, hemorrhage)
    • thrombophlebitis in the lower extremity
    • elevated or depressed temperature
    • any number of problems with the incision/wound (dehiscence, evisceration, infection)
    • fluid and electrolyte imbalances
    • urinary retention
    • constipation
    • surgical pain
    • nausea/vomiting (paralytic ileus)
    to plan care, follow the steps of the nursing process. . .

    step 1 assessment - assessment consists of:
    • a health history (review of systems) - the burning question i have is why this man had to have this surgery??? no one just shows up to have a lobe of their lung cut out for no reason. does he have cancer?
    • performing a physical exam - for someone who has had lung surgery you list no lung sounds, no breathing information, nothing about an assessment of the chest tube (what is draining or how much), what the dressing looks like, what kind of coughing the patient is doing, any sputum production, how much and what it looks like. i worked with these kinds of patients and post-op pneumonia is a huge concern. he should be deep breathing and coughing. with copd it is a even bigger concern. is he having any pain?
    • assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - ????
    • reviewing the pathophysiology, signs and symptoms and complications of their medical condition - at least copd should be looked up along with its signs and symptoms as well as the underlying reason for surgery, especially if it was for cancer.
    • reviewing the signs, symptoms and side effects of the medications/treatments that have been ordered and that the patient is taking - a chest tube and oxygen are medical treatments. is he on pain medication? thoracotomies are extremely painful.
    step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all you listed was the following:
    • complains of sob while at rest, and more so after ambulating 125 feet
    step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
    • activity intolerance r/t imbalance between oxygen supply and demand aeb sob after ambulating 125 feet
    • i would expect these nursing problems, but cannot diagnose them because of the lack of data:
      • impaired gas exchange
      • ineffective airway clearance
      • ineffective breathing pattern
      • acute pain
      • impaired tissue integrity
      • risk for infection


    i'm thinking impaired gas exchange related to decreased functional lung tissue secondary to lung lobectomy
    impaired gas exchange is defined as excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane (page 112, nanda international nursing diagnoses: definitions and classifications 2009-2011). the related factor, or cause, of the problem (your related to part of the diagnostic statement) needs to explain why the alveoli are not functioning so that there has been an excess or deficit in oxygen or carbon dioxide elimination (gasses passing back and forth across the alveolar membrane). decreased functional lung tissue secondary to lung lobectomy isn't telling us what has happened to impair this process. you need to know the pathophysiology of the disease process going on and how it has affected the cells (alveoli) of the lung. copd causes permanent changes in the alveoli that damages this gas exchange ability. the nanda taxonomy calls this alveolar-capillary membrane changes. even if this patient had cancer alveolar-capillary membrane changes would apply as well because the cancer cells would be taking over and consuming the alveoli so that gas exchange cannot occur between the alveoli and the capillaries. and, it would not be secondary to a lobectomy. a lobectomy merely cuts into lung tissue and has nothing to do with altering the physical structure of the cells themselves. this diagnosis used for a copd patient is worded as impaired gas exchange r/t alveolar-capillary membrane changes.
    where and how do i fit chest tube care into that diagnosis/careplan?
    a chest tube is a medical treatment. the doctor places a chest tube in the pleural space to expand the lung and remove both air from the pleural space and blood from the operative area. interventions for it can be included with the nursing treatments for the signs and symptoms of ineffective breathing pattern. see this older thread for nursing interventions for chest tube care: - care for chest wound patient? (includes weblinks to information about chest tubes)

    for more information on the construction of care plans and examples, see - help with care plans
  6. by   FE710
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]NDx Ineffective Breathing Pattern
    NANDA: Inspiration and/or expiration that does not provide adequate ventilation
    Ineffective breathing patterns are considered a state in which the rate, depth, timing, rhythm or chest/abdominal wall excursion during inspiration, expiration or both do not maintain optimum ventilation for the individual. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure may be associated with changes in respiratory rate, normal abdominal and thoracic patterns for inspiration and expiration, and in depth of ventilation. Breathing pattern changes may occur in a multitude of conditions: heart failure, diaphragmatic paralysis, airway obstruction, respiratory infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment and/or pain, cognitive impairment and anxiety, metabolic abnormalities (e.g., diabetic ketoacidosis, uremia, or thyroid dysfunction), peritonitis, drug overdose, pleural inflammation, and chronic respiratory disorders such as asthma or chronic obstructive pulmonary disease (COPD).
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]Common Related Factors
    Inflammatory process: viral or bacterial
    Neuromuscular impairment
    Musculoskeletal impairment
    Decreased energy and fatigue
    Tracheobronchial obstruction
    Perception or cognitive impairment
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]Defining Characteristics
    Nasal flaring
    Respiratory depth changes
    Altered chest excursion
    Use of accessory muscles
    Pursed-lip breathing or prolonged expiratory phase
    Increased anteroposterior chest diameter
    Irregular or paradoxical breathing
    Abnormal arterial blood gas (ABG)
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]Common Expected Outcome
    Patient's breathing pattern is effectively maintained as evidenced by eupnea, normal skin color, and minimal or no complaints of dyspnea.
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]NOC Outcomes
    Respiratory Status: Ventilation;
    Vital Sign Status
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]NIC Interventions
    Airway Management;
    Respiratory Monitoring
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]Ongoing Assessment

    -Assess respiratory rate, rhythm, and depth.
    Rationale: Respiratory rate and rhythm changes are early warning signs of impending respiratory difficulties.
    -Assess for the quality, duration, intensity, and distress associated with dyspnea.
    Rationale:This facilitates the evaluation of the patient's response to therapy and activity.
    -Inquire about precipitating and alleviating factors.
    Rationale: Knowledge of these factors is useful in planning interventions to prevent or manage future episodes of dyspnea.
    -Assess nutritional status (e.g., weight and albumin and electrolyte levels).
    Rationale: Malnutrition may result in premature development of respiratory failure because it reduces respiratory mass and strength. It blunts ventilatory responses to hypoxia and impairs pulmonary and systemic immunity. Over-feeding increases production of CO2, which increases respiratory drive and respiratory muscle fatigue.
    -Monitor breathing patterns:
    Rationale: Specific breathing patterns may indicate an underlying disease process or dysfunction. Cheyne-Stokes respiration usually represents bilateral dysfunction in the deep cerebral hemispheres associated with brain injury or metabolic abnormalities. Apneusis and ataxic breathing and Biot's respirations are associated with failure of the respiratory centers in the pons or medulla.
    * Bradypnea (slow respirations)
    * Tachypnea (increase in respiratory rate)
    * Hyperventilation (increase in respiratory rate or tidal volume, or both)
    * Kussmaul's respirations (deep respirations with fast, normal, or slow rate)
    * Cheyne-Stokes respiration (waxing and waning with periods of apnea between a repetitive pattern)
    * Apneusis (sustained maximal inhalation with pause)
    * Biot's respirations (irregular periods of apnea alternating with periods in which four or five breaths of identical depth are taken)
    * Ataxic patterns (irregular and unpredictable pattern with periods of apnea)
    -Observe for excessive use of accessory muscles (scalene and sternocleidomastoid).
    Rationale: This is indicative of increased respiratory effort.
    -Monitor for diaphragmatic muscle fatigue or weakness (paradoxical motion).
    Rationale: Paradoxical movement of the abdomen (an inward versus outward movement during inspiration) is indicative of respiratory muscle fatigue and weakness.
    - Note retractions or flaring of nostrils.
    Rationale: These signify an increase in respiratory effort.
    -Assess the position that the patient assumes for breathing.
    Rationale: A three-point position or orthopnea is associated with breathing difficulty.
    -Use pulse oximetry to monitor oxygen saturation and heart rate.
    Rationale: Pulse oximetry is a useful tool to detect early changes in oxygenation; however, for CO2 levels, capnography or ABGs would need to be obtained.
    -Monitor ABGs as appropriate; note changes.
    Rationale:Increasing PaCO2 and decreasing PaO2 are signs of respiratory failure. As the patient's condition begins to fail, the respiratory rate decreases and PaCO2 begins to increase.
    -Monitor for changes in orientation, increased restlessness, anxiety, lethargy and somnolence.
    Rationale: Restlessness is an early sign of hypoxia. Lethargy and somnolence are late signs of hypoxia.
    -Avoid high concentration of oxygen in patients with COPD unless ordered.
    Rationale: Hypoxia stimulates the drive to breathe in the chronic CO2 retainer patient. When applying oxygen, close monitoring is imperative to prevent unsafe increases in the patient's PaO2, which could result in apnea.
    -Assess skin color and temperature.
    Rationale: Cyanosis occurs when at least 5 g of hemoglobin is desaturated. Cool pale skin may be secondary to a compensatory/vasoconstrictive response to hypoxemia.
    -Monitor vital capacity in patients with neuromuscular weakness and observe trends.
    Rationale: Monitoring detects changes early so ventilatory support may be initiated before full decompensation occurs.
    -Assess sputum for quantity, color, consistency, and odor.
    Rationale: These may be indicative of an etiology for the alteration in breathing pattern.
    -If the sputum is discolored (no longer clear or white), send the specimen for culture and sensitivity testing, as appropriate.
    Rationale: An infection may be present. Respiratory infections increase the work of breathing, resulting in fatigue and changes in breathing pattern. Antibiotic treatment may be indicated.
    -Assess ability to clear secretions.
    Rationale: An obstructed airway may cause a change in breathing pattern.
    -Assess for thoracic or upper abdominal pain.
    Rationale: These can result in shallow breathing.
    -Assess use of herbal remedies (e.g., ma huang for bronchospasm, or licorice and hyssop for reducing cough and promoting expectoration).
    Rationale: Drug interactions with prescribed medications and contraindications need to be evaluated (e.g., ma huang contains ephedrine, which should not be used by patients with hypertension, heart disease, prostatic hyperplasia, or diabetes).
    [FONT=Andale Sans for VST][FONT=Andale Sans for VST]Therapeutic Interventions

    -Position the patient with proper body alignment for optimal breathing pattern.
    Rationale: If not contraindicated, a sitting position allows for good lung excursion and chest expansion.
    -Ensure that the oxygen delivery system is applied to the patient.
    Rationale: The appropriate amount of oxygen is continuously delivered so that the patient does not desaturate. An oxygen saturation of 90% provides for adequate oxygenation.
    -Encourage sustained deep breaths by:
    Rationale: These techniques promote deep inspiration that increases oxygenation and prevents atelectasis. Controlled breathing techniques may also help slow respirations in patients who are tachypneic.
    * Using demonstration (emphasizing slow inhalation, holding end inspiration for a few seconds, and passive exhalation)
    * Using incentive spirometer (place close for convenient patient use)
    * Asking the patient to yawn
    -Evaluate appropriateness of inspiratory muscle training.
    Rationale: This improves conscious control of respiratory muscles and inspiratory muscle strength.
    -Encourage the patient to clear his or her own secretions with effective coughing. If secretions cannot be cleared, suction as needed to clear secretions.
    Rationale: This promotes airway patency.
    -Use universal precautions (e.g., gloves, goggles, and mask) as appropriate. If secretions are purulent, precautions should be instituted before receiving the culture and sensitivity final report. Institute appropriate isolation procedures for positive cultures (e.g., methicillin-resistant Staphylococcus aureus or tuberculosis).
    Rationale: These measures prevent transmission of pathogenic microorganisms.
    -Pace and schedule activities, providing adequate rest periods. Assist with ADLs.
    Rationale: This prevents dyspnea resulting from fatigue and excessive oxygen demand.
    -Provide reassurance and allay anxiety by staying with the patient during acute episodes of respiratory distress.
    Rationale: Anxiety can increase dyspnea and respiratory rate.
    -Provide relaxation training as appropriate (e.g., biofeedback, imagery, progressive muscle relaxation).
    Rationale: This reduces pain and anxiety through distraction.
    -Encourage diaphragmatic breathing for the patient with chronic disease.
    Rationale: This relaxes muscles and increases the patient's oxygen level.
    -Use pain management as appropriate.
    Rationale: This allows for pain relief and the ability to deep breathe and cough.
    -Anticipate the need for intubation and mechanical ventilation if the patient is unable to maintain adequate gas exchange with the present breathing pattern.
    Rationale: Early intubation and mechanical ventilation are recommended to prevent full decompensation of the patient and a potentially life-threatening situation. Mechanical ventilation may be needed to maintain adequate oxygenation and ventilation.
    (Gulanick, Meg. Nursing Care Plans: Nursing Diagnosis and Intervention, 6th Edition. Mosby, 102006. 2.8).
  7. by   irkedoneSN
    Thanks guys so much. I ended up using ineffective airway clearance and impaired gas exchange! Thanks again for your help!
  8. by   NottaSpringChik
    And he does have impaired skin integrity too, doesn't he? Has incision from lobectomy and a chest tube.
  9. by   missy--kay
    I always use Knowledge deficit in care plans.... there is ALWAYS something you can teach your patients!!

    Good luck!!