8.4 Putting It All Together
Open Resources for Nursing (Open RN)
The following client scenario applies information from this chapter to create an abbreviated nursing care plan and sample documentation note.
Client Scenario
Mr. Smith is an 82-year-old client with a history of chronic obstructive pulmonary disease (COPD). This morning Mr. Smith told the CNA as he was getting ready for breakfast, “I’m feeling weak today and I can’t breathe.” The CNA obtained vital signs and reported them to you: respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. View a video simulation of Mr. Smith in the following box.
View a YouTube[1] of Mr. Smith this morning:
Applying the Nursing Process
Assessment: You auscultate Mr. Smith’s breath sounds and find scattered wheezing and rhonchi anteriorly, with diminished breath sounds in the posterior lower lobes. You ask Mr. Smith to rate his shortness of breath now on a scale from 0-10, and he reports it is a “4,” but usually a “2” during activity. While assessing Mr. Smith, you note he is using accessory muscles to breathe and is sitting up in the tripod position. He also has a barrel chest. You quickly check his chart and note the following orders and scheduled medications:
- Tiotropium (Spiriva) inhaler daily
- Fluticasone (Flovent) inhaler daily
- Oxygen via nasal cannula at 1-2 L per minute as needed to maintain O2 saturation greater than 90%
- Albuterol nebulizer as needed for wheezing
Based on this information, you formulate the following nursing care plan:
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea and use of accessory muscles to breathe and client stating, “I’m feeling weak today and I can’t breathe.”
Overall Goal: The client will have adequate movement of air into and out of the lungs.
SMART Expected Outcome: Mr. Smith’s reported level of dyspnea will be within his stated desired range of 1-2 within one hour.
Planning and Implementing Nursing Interventions:
| Interventions | Rationale |
|---|---|
| 1. Implement NIC interventions for Respiratory Monitoring NIC (as described in section 8.3). | Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented. |
| 2. Implement NIC Interventions for Anxiety Reduction (as described in section 8.3). | Dyspnea creates feelings of anxiety. Decreasing the client’s anxiety levels will help decrease the feeling of dyspnea. |
| 3. Place client in high Fowler’s or tripod position as needed to reduce feelings of dyspnea. | Positioning will assist in maximum expansion of lungs. |
| 4. Apply oxygen via nasal cannula, starting at 1 L/min and titrate until 90% pulse oximetry reading is obtained per standing order. | Oxygen therapy will reduce the work of breathing. |
5. Administer scheduled and PRN medications:
|
Each medication has a different mechanism of action that will assist Mr. Smith’s dyspnea.
|
| 6. Encourage Mr. Smith to use pursed-lip breathing and Huff coughing. | Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions. |
| 7. Encourage fluids (2000 mL/24 hours) and monitor intake and output. | Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly clients who have increased risk for developing fluid overload. |
| 8. Schedule care activities to allow frequent rest periods. | Resting frequently decreases oxygen demand. |
| 9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. | Ambulation will help to mobilize the secretions so they can be removed. |
Sample Documentation:
Upon awakening, the client reported a dyspnea level of a “4” and stated, “I’m feeling weak today and I can’t breathe.” Vital signs were respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. Scattered wheezing and rhonchi present anteriorly, with diminished breath sounds in the posterior lower lobes. Oxygen applied via nasal cannula at 1 L/min; albuterol nebulizer and scheduled medications were administered. Client was placed in tripod position at edge of bed and encouraged to use pursed-lip breathing and Huff coughing. Post albuterol administration, vital signs were respiratory rate 16, pulse 78, and O2 sat 90% on room air. The wheezing and rhonchi in the anterior lungs were diminished. Client reported dyspnea decreased to a “2” but stated, “I feel less short of breath, but I am still tired.” Encouraged client to push fluids and ambulate as tolerated today, along with frequent rest breaks. Will continue to monitor respiratory rate, pulse, lung sounds, and reported level of dyspnea every four hours today.
Evaluation:
After administering medications and applying the oxygen, you reassess Mr. Smith and find the following: respiratory rate 16, pulse 78, and O2 sat 90% with NC at 1 L/min. The wheezing and rhonchi in the anterior lungs have diminished. You ask Mr. Smith how he is feeling. He rates his current level of dyspnea as a “2” and states, “I feel less short of breath, but I am still tired.” The SMART outcome was “met.” You encourage Mr. Smith to rest after eating breakfast but encourage a walk in the hallway later that morning. You enter the documentation note in the client record.
- Open RN Project. (2020, March 26). ARISE Simulated Patient Video, Heart Failure Nursing Level 3 - 1027. [Video]. YouTube. CC BY 4.0. https://www.youtube.com/watch?v=2WFARSE9xs0 ↵