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 & Suddarths Medical Surgical Nursing, Page 190) Cues Objective: Tachypnea: 26 breathes per minute Decreased respiratory depth Cyanotic STO: After 10 minutes of nursing intervention, the patient will be able to decrease breathes per minute from 26 to 1220. LTO: After 20 minutes of nursing intervention, the patient will establish normal breathing pattern as evidenced by the Expected Outcome Nursing Interventions Independent actions: 1. Administer oxygen at lowest concentration indicated and prescribed respiratory medications. 2. Monitor pulse oximeter, as indicated. 3. Suction airway, as needed. 4. Elevate head of bed, as appropriate. 5. Provide/encourage use of adjuncts, such as incentive spirometer. Rationale Independent actions: 1. For management of underlying pulmonary condition, respiratory distress, or cyanosis. 2. To verify maintenance and improvement in oxygen saturation. 3. To clear secretions. 4. To promote physiological ease of maximal inspiration. 5. To facilitate deeper respiratory effort. Goal met, the patient established LTO: Evaluation STO: Goal met, the patient was able to decrease breathes per minute from 26 to 12-20.

absence of cyanosis.

normal breathing pattern as evidenced by the absence of cyanosis.

References: Nurses Pocket Guide Pages 151-155