The RN will update the plan of care by resolving the nursing diagnoses of ineffective breathing pattern related to hyperventilation as evidenced by shortness of breath and respirations of 28 breaths per minute and the diagnosis of activity intolerance related to imbalance between oxygen supply and demand as shown by shortness of breath when ambulating. These diagnoses have been resolved by the patient meeting the expected outcome within 24 hours. The patient has a respiratory rate of 20 breaths per minute and denies any shortness of breath with ambulation.
The remaining diagnosis of impaired gas exchange related to ventilation perfusion imbalance as evidence by the oxygen saturation of 90% is still applicable due to the patient’s oxygen saturation not being greater than 95% in 24 hours. One intervention to include would be to help the client take deep breaths and perform controlled coughing. (Ladwig, Ackley, & Makic, 2017) The RN can carry out this by having the patient hold the breath for several seconds and coughing while the mouth is …show more content…
One intervention to include for this diagnosis would be completing chest physiotherapy. (Ladwig, Ackley, & Makic, 2017) This response would include postural drainage (positioning to promote drainage), chest percussion (rhythmic clapping of the chest wall with cupped hands) and chest vibration (vibrating the chest wall with the palms of hands). (Treas and Wilkinson, 2014) Using these together will help promote the loosening and mobilize the mucus. (Treas and Wilkinson, 2014)
References
Ladwig, G.B., Ackley, B.J., Makic, M. (2017) Mosby's Guide to Nursing Diagnosis. St. Louis, Missouri: Elsevier Inc., 5th Ed.
Treas, L, and Wilkinson, J.(2014): Basic Nursing Concepts, Skills, and Reasoning. F.A. Davis
The remaining diagnosis of impaired gas exchange related to ventilation perfusion imbalance as evidence by the oxygen saturation of 90% is still applicable due to the patient’s oxygen saturation not being greater than 95% in 24 hours. One intervention to include would be to help the client take deep breaths and perform controlled coughing. (Ladwig, Ackley, & Makic, 2017) The RN can carry out this by having the patient hold the breath for several seconds and coughing while the mouth is …show more content…
One intervention to include for this diagnosis would be completing chest physiotherapy. (Ladwig, Ackley, & Makic, 2017) This response would include postural drainage (positioning to promote drainage), chest percussion (rhythmic clapping of the chest wall with cupped hands) and chest vibration (vibrating the chest wall with the palms of hands). (Treas and Wilkinson, 2014) Using these together will help promote the loosening and mobilize the mucus. (Treas and Wilkinson, 2014)
References
Ladwig, G.B., Ackley, B.J., Makic, M. (2017) Mosby's Guide to Nursing Diagnosis. St. Louis, Missouri: Elsevier Inc., 5th Ed.
Treas, L, and Wilkinson, J.(2014): Basic Nursing Concepts, Skills, and Reasoning. F.A. Davis