Breathing

8/2016Nursing Care Plan Ineffective Breathing pattern | Linda Cort

Breckinridge School of Nursing @ ITT Technical Institute Nursing Diagnosis: Ineffective breathing pattern related to decreases in lung expansion from pressure on the diaphragm from excessive weight as evidence by episodes heavy snoring and gasping for air during sleep Assessment Outcome (Goals) Nursing Interventions/Rationales Evaluation (short term, reasonable (List 3 Interventions) (Goal met/unmet) expectations, action verbs) 1. Nurse to assess respiratory status Goal met clients o2 SUBJECTIVE: Client will demonstrate of client every four hours taking note saturations remained Client report “I sleep for 8 effective breathing of breath sounds, rate, rhythm, and between 97% to 100% hours a night but I am tired all patterns as evidence by proper placement/reading of pulse respiration remained the time” O2 saturations ranging oximetry every 4 hours (1800, 2200, consistent at 16 with a Wife reports “He snores so from 95% to 100%, 0200., and 0600) and notify provider regular rate and rhythm. loud and the starts gasping” respiratory rate of 14-20 of o2 saturations less than 95% Client reports smoking 2 packs breathes per minute decreases in rate or rhythm. by a day regular rate and rhythm monitoring the client’s status throughout the night on changes in stat8s will be detected 1/28/2016. and intervention can take place timely manner.

____________________________ _ OBJECTIVE: 66-year-old-male, weighs 226 lbs. Dx. HTN, Type 2 Diabetes, sleep study new diagnosis of sleep apnea, CPAP machine has been ordered for NOC, scheduled for gastric bypass in AM.

2. Nurse to educate client on using pursed lip breathing during periods of difficulty breathing pattern at 1800. Pursed lip breathing has proven to increase oxygen levels. 3. 4. Client will demonstrate how to perform pursed lip breathing at 1830. By having client perform pursed lips breathing techniques the nurse can evaluate his understanding of what he was taught. Page 1 of 3

8/2016Nursing Care Plan Ineffective Breathing pattern | Linda Cort

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8/2016Nursing Care Plan Ineffective Breathing pattern | Linda Cort

References Ackley, B. J., & Ladwig, G. B. (2015). Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. Missouri: Mosby, Elseveir.

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