Ineffective breathing pattern care plan: This nursing care plan and diagnosis is for the following condition: Ineffective Breathing Pattern, Dyspnea, Respiratory Distress Syndrome, Hypoxia, Acute Respiratory Failure, Hypoxemia, and Respiratory Illness
What are nursing care plans? How do you develop a nursing care plan? What nursing care plan book do you recommend helping you develop a nursing care plan?
This care plan is listed to give an example of how a Nurse (LPN or RN) may plan to treat a patient with those conditions.
Important Disclosure: Please keep in mind that these care plans are listed for Example/Educational purposes only, and some of these treatments may change over time. Do not treat a patient based on this care plan.
Care Plans are often developed in different formats. The formatting isn’t always important, and care plan formatting may vary among different nursing schools or medical jobs. Some hospitals may have the information displayed in digital format, or use pre-made templates. The most important part of the care plan is the content, as that is the foundation on which you will base your care.
Nursing Care Plan for: Ineffective Breathing Pattern, Dyspnea, Respiratory Distress Syndrome, Hypoxia, Acute Respiratory Failure, Hypoxemia, and Respiratory Illness
If you want to view a video tutorial on how to construct a care plan in nursing school, please view the video below. Otherwise, scroll down to view this completed care plan.
Scenario: |
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An 86 year old female comes into the ER. Pt states she has been extremely short of breath for the past 12 hours and you note she is only about to state 2-3 words before she stops and has to breathe again. You note she is using her accessory muscles to help her breathe. Collecting health history is difficult. Pt came in on her home oxygen tank and you note the oxygen setting is on 4 Liters. The pt states her normal oxygen setting is 2 L but since she has became short of breath she increased it to 4 liters but says it hasn’t helped and that is why she come to the ER. Pt breathing is fast and irregular (especially on activity and exertion). You hook the patient up to cardiac monitor and find her oxygen saturation to be 85%, HR 112, BP 150/86, and RR 36. Lungs sounds are diminished and hard to hear. Chest X-ray shows hyper-inflated lungs with flatten diaphragm correlating with COPD. ABGS show PCO2 60, pH 7.25, PO2 50, O2 Sat 85%.
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Nursing Diagnosis: |
| Ineffective Breathing Pattern related to hypoxia as evidence by shortness of breath with activity, use of accessory muscles, O2 saturation of 85%, and abnormal ABGS. |
Subjective Data: |
| Pt states she has been extremely short of breath for the past 12 hours, pt states her normal oxygen setting is 2 L but since she has became short of breath she increased it to 4 liters but says it hasn’t helped and that is why she come to the ER. |
Objective Data: |
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You note she is only about to state 2-3 words before she stops and has to breathe again. You note she is using her accessory muscles to help her breathe. Collecting health history is difficult. Pt came in on her home oxygen tank and you note the oxygen setting is on 4 Liters. The Pt breathing is fast and irregular (especially on activity and exertion). You hook the patient up to cardiac monitor and find her oxygen saturation to be 85%, HR 112, BP 150/86, and RR 36. Lungs sounds are diminished and hard to hear. Chest X-ray shows hyper-inflated lungs with flatten diaphragm correlating with COPD. ABGS show PCO2 60, pH 7.25, PO2 50, O2 Sat 85%
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Nursing Outcomes: |
| -Pt oxygen saturation will be 90-100% throughout hospitalization.-Pt respiratory rate will be 12-20 breaths per minute throughout hospitalization
-Pt will demonstrate two breathing techniques to use during dyspneic episodes within 12 hours. -Pt will verbalized two ways on how to prevent COPD exacerbation. |
Nursing Interventions: |
| -The nurse will place the pt on bipap per md order and assess patient’s oxygen saturation every 30 minutes.-The nurse will assess pt respiratory rate every 30 minutes within the first 8 hours and then every 4 hours when the patients respiratory rate is 12-20 breaths per minute during hospitalization.
-The nurse will verbalized and demonstrate to the patient 4 breathing techniques to use during dyspneic episodes within 6 hours of the hospitalization. -The nurse will verbalize four ways on how to prevent COPD exacerbation to the patient within 12 hours of hospitalization. |