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Nursing Care Plan: References: Nurse's Pocket Guide Pages 151-155

The patient was experiencing difficulty breathing with an ineffective breathing pattern due to decreased lung expansion after surgery, evidenced by decreased respiratory depth and increased breathing rate of 26 breaths per minute. The nursing care plan aimed to decrease the patient's breathing rate to between 12-20 breaths per minute within 10 minutes through administering oxygen, monitoring their pulse oximeter, suctioning their airway if needed, and elevating their head; and to establish a normal breathing pattern without cyanosis within 20 minutes through these interventions and using an incentive spirometer.

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Nursing Care Plan: References: Nurse's Pocket Guide Pages 151-155

The patient was experiencing difficulty breathing with an ineffective breathing pattern due to decreased lung expansion after surgery, evidenced by decreased respiratory depth and increased breathing rate of 26 breaths per minute. The nursing care plan aimed to decrease the patient's breathing rate to between 12-20 breaths per minute within 10 minutes through administering oxygen, monitoring their pulse oximeter, suctioning their airway if needed, and elevating their head; and to establish a normal breathing pattern without cyanosis within 20 minutes through these interventions and using an incentive spirometer.

Uploaded by

Caroline Cha
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Nursing Care Plan

Problem Identified: Difficulty of breathing

Nursing Diagnosis: Ineffective breathing pattern related to decreased lung expansion secondary to surgery as evidenced by decreased respiratory depth.
Cause Analysis: Respiratory depression is the most serious adverse effect of opioid analgesics administered by IV, SubQ, or epidural routes. Specific notable changes are
decreasing respiratory rate or shallow respirations. (Brunner & Suddarth’s Medical Surgical Nursing, Page 190)

Cues Expected Outcome Nursing Interventions Rationale Evaluation

Objective: STO: Independent actions: Independent actions: STO:

Tachypnea: 26 breathes After 10 minutes of nursing 1. Administer oxygen at lowest 1. For management of underlying Goal met, the patient
per minute intervention, the patient will be concentration indicated and pulmonary condition, respiratory was able to decrease
Decreased respiratory able to decrease breathes per prescribed respiratory medications. distress, or cyanosis. breathes per minute
depth minute from 26 to 12-20. 2. Monitor pulse oximeter, as indicated. 2. To verify maintenance and from 26 to 12-20.
Cyanotic 3. Suction airway, as needed. improvement in oxygen saturation.
LTO: 4. Elevate head of bed, as appropriate. 3. To clear secretions. LTO:
5. Provide/encourage use of adjuncts, 4. To promote physiological ease of
After 20 minutes of nursing such as incentive spirometer. maximal inspiration. Goal met, the patient
intervention, the patient will 5. To facilitate deeper respiratory established normal
establish normal breathing effort. breathing pattern as
pattern as evidenced by the evidenced by the
absence of cyanosis. absence of cyanosis.

References: Nurse’s Pocket Guide Pages 151-155

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