Ineffective Breathing Nursing Care Plan

Situation: Mrs. Hernandez is a 72-year-old Hispanic female who was admitted to the medical unit yesterday afternoon with a diagnosis of pneumonia in her right lobe. Chest X-ray shows infiltrates in right lower lobe, indicative of pneumonia. She was started on antibiotics after a sputum specimen for Gram stain culture was obtained. We are monitoring her respiratory status closely.

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Background: Mrs. Hernandez was experiencing symptoms of dry cough, fever, and malaise, and was diagnosed with influenza 10 days prior to admission. Her symptoms got progressively worse, and yesterday she had a temperature of 38.4 °C (101.2 °F), shaking, chills, and a productive cough of rust-colored sputum. Her primary care provider saw her yesterday and decided to admit her for treatment of pneumonia.

Assessment: Mrs. Hernandez is alert and oriented ×3, but appears tired. She reports sharp chest pain with coughing and shortness of breath with activity. She rated the pain as a 6 on a scale of 0–10 and was given acetaminophen 650 mg at 1400. Vitals signs were taken at 1200. Her temperature has been elevated since this morning and was 38.1 °C (100.6 °F). Pulse is 104/min, respirations 24/min, and blood pressure 112/72 mm Hg. Her saturation was 95% on nasal cannula with oxygen at 3 L/min. Her respirations were labored when she came back from the bathroom, but improved when she settled back in bed.

Recommendation: You should make sure to maintain saturation levels above 94%. Mrs. Hernandez needs encouragement to cough and deep breathe, and to use incentive spirometry. She only uses her incentive spirometer after much encouragement. You should also start patient education on disease process and management.

1. Choose one approved Nanda Diagnosis

2. Include 3 risk factors

3. Include 3 expected outcomes

4. Include 4 nursing interventions

5. Include 2 collaborative interventions

6. Include 2 evaluations (how will you evaluate your interventions are working to meet your outcomes)

Example:

Nanda Diagnosis: Risk for activity intolerance

Risk Factors:

Immobility
Inexperience with an activity
Physical deconditioning
Expected Outcomes:

The patient will maintain joint range-of-motion and muscle strength.
The patient will maintain the ability to perform daily activities at the highest level without abnormal changes in vital signs in response to activity.
The patient will verbalize feelings of improvement in activity status.
Nursing Interventions:

Assess the patient’s history for factors that may impair activity tolerance. Discuss factors that can produce fatigue in the patient, and help identify ways to reduce factors.
Assess the patient’s level of functioning.
Assess the patient’s vital signs for activity intolerance.
Encourage progressive self-care or participation in activities, when tolerated; identify and acknowledge the patient’s progress.
Collaborative:

Assist with strengthening exercises as prescribed, and monitor response.
Obtain a physical therapy consult, as indicated.
Evaluation:

The patient maintains joint range-of-motion and muscle strength.
The patient verbalizes feelings of improvement in activity status.