Question

Allergy: Penicillin

M.J. is a 67 y/o male with a dx of CHF. Pt states, “I get short of breath before I’m able to make it from the bed to the bathroom.” You also notice the pt leaning forward in the bed to breathe.

Vital Signs:

Pulse: 92 BPM and Regular

Respiratory Rate: 28 BPM

SpO2 Right Index Finger: 95% on 4 L by NC

Blood Pressure: 146/92 Right Upper Extremity

Temperature: 37.1^oC

IV: 20g PIV placed in the left wrist. IV was placed yesterday by EMS and flushes well. The dressing is clean, dry, and intact.

I&O:

Intake: 125 mL/hr of IV 0.45% Saline

Output:

1 Large Dark Brown Stool

450 mL of Straw Colored Urine

Respiratory Assessment

Accessory muscle use noted. Breathing is labored. Coarse crackles present bilaterally in the lower posterior lung fields. Productive cough with pink frothy sputum.

Safety and Management

Mental status is alert and oriented x 4.  

Develop a nursing diagnosis and plan for a patient using the above information.

Answer 1

Nursing Diagnosis;
Ineffective breathing pattern related to decreased lung expansion as characterized by use of accessory muscles.

Plan/Nursing interventions;
*elevate the head of the bed to 30 degrees to promote proper ventilation.
*assess respiratory rate and depth.
*ensure O2 delivery system.
*use pulse oximetry to monitor the saturation changes early.
*monitor ARTERIOR BLOOD GAS analysis for signs of respiratory failure.
*assess the ability to clear secretions.
*provide steam inhalations to clear the secretions.
*encourage for deep breathing to sustain deep inspiration.
*teach the patient when to inhale and exhale while doing sternuous activities.