13.4 Putting It All Together

Client Scenario

Mrs. Howard is a 73-year-old woman who was recently admitted to the medical-surgical floor with pneumonia. She has an underlying history of emphysema and has experienced a recent exacerbation of dyspnea during activity. This morning when being assisted to the bathroom, she reports, “I have to stop and catch my breath when walking.” Vital signs this morning indicated oxygen saturation 91% and respiratory rate 18 on room air at rest. During report it was communicated that Mrs. Howard is able to ambulate with the assistance of one but only moves short distances around the room before she needs to stop and rest.

Applying the Nursing Process

Assessment: The nurse identifies a relevant cue that the client, diagnosed with pneumonia and a previous history of emphysema, is experiencing increased dyspnea when walking around the room that requires her to stop and rest. The nurse gathers additional assessment data while the client is walking and discovers her respiratory rate increases to 30 and her oxygen saturation level decreases to 85% after walking for two minutes. Additionally, the client stops and catches her breath after walking approximately 10 feet, causing her to limit her mobility.

The nurse reviews the client’s chart and finds an order for “Oxygen via nasal cannula up to 5 L/min PRN to maintain oxygen saturation at 90%.” The nurse also notes a referral for physical therapy evaluation and strengthening exercises.

Based on the assessment information gathered, the following nursing care plan is created for Mrs. Howard:

Nursing Diagnosis: Impaired Physical Mobility r/t activity intolerance as manifested by client unable to ambulate more than ten feet without respiratory symptoms and client report of “I have to stop and catch my breath while walking.”

Overall Goal: The client will demonstrate improvement in mobility.

SMART Expected Outcomes:

• Mrs. Howard will ambulate 50 feet in the hallway within 24 hours.
• Mrs. Howard will maintain an oxygen saturation level of 90% or higher while ambulating within 24 hours.

Planning and Implementing Nursing Interventions:

The nurse plans to administer oxygen to the client via nasal cannula as needed to maintain an oxygen saturation level of 90% or higher. The nurse will teach the client about the importance of balancing periods of activity with periods of rest and reinforce the use of pursed-lip breathing. The nurse will encourage client ambulation and her active participation in completing ADLs. The nurse will collaborate with physical therapy to educate the client regarding strengthening exercises and reinforce principles of progressive exercise. The nurse plans to further assess the client’s smoking history and promote smoking cessation.

Sample Documentation:

At 0800 when assisting the client to the bathroom, the client reported, “I have to stop and catch my breath when walking.” At 0830, vital signs were reassessed while the client was walking. Her respiratory rate increased to 30 and her oxygen saturation level decreased to 85% after 2 minutes of walking. The client stopped to catch her breath after walking approximately 10 feet. Oxygen via nasal cannula at 1 L/min was applied to the client before ambulating in the hallway at 1000. The client’s oxygen saturation level dropped to 88% after one minute of walking and the oxygen was increased to 2 L/min. The client’s oxygen saturation then remained at 90% for the remainder of the walk, and she was able to ambulate 50 feet. Pursed-lip breathing was demonstrated and reinforced during the walk. Physical therapy was contacted, and an evaluation scheduled for later this morning. The client reports a smoking history of a pack per day for 50 years and states she is interested in stopping smoking. A smoking cessation brochure was provided and discussed. Dr. Smith was notified of these events at 1030.

Evaluation:

Within 24 hours, Mrs. Howard successfully ambulated 50 feet in the hallway while maintaining oxygen saturation level of 90%. SMART outcomes were “met.” Planned interventions will continue. SMART outcome is revised to, “Mrs. Howard will ambulate 100 feet in the hallway within 24 hours.”