NURSING DX 1: INEFFECTIVE BREATHING PATTERN R/T HYPOXIA AEB LOW O2 SAT OF 90% AND SOB.

INTERVENTIONS: ENSURE THAT OXYGEN DELIVERY SYSTEM IS APPLIED TO THE PATIENT- THE APPROPRIATE AMOUNT OF OXYGEN IS CONTINUOUSLY DELIVERED SO THAT THE PT DOES NOT DESATURATE. AN OXYGEN SATURATION OF 90% OR GREATER SHOULD BE MAINTAINED. THIS PROVIDES FOR ADEQUATE OXYGENATION. ENCOURAGE DEEP BREATHING & COUGHING EXERCISES. POSITION PT FOR OPTIMAL BREATHING PATTERN- HOB >30 DEGREES. MAINTAIN A CLEAR AIRWAY BY ENCOURAGING PT TO CLEAR OWN SECRETIONS WITH EFFECTIVE COUGHING- IF SECRETIONS CAN NOT BE CLEARED, SUCTION AS NEEDED TO CLEAR SECRETIONS. PACE AND SCHEDULE ACTIVITIES PROVIDING ADEQUATE REST PERIODSTHIS PREVENTS DYSPNEA RESULTING FROM FATIGUE. USE PAIN MANAGEMENT AS APPROPRIATE- THIS ALLOWS FOR PAIN RELIEF AND THE ABILITY TO DEEP BREATHE.

GOALS: PT WILL HAVE NO SOB AND WILL MAINTAIN O2 SAT >90% W/ NC THROUGHO UT THE SHIFT 7A-1P.

EVALUATION: PT SHOWS NO S/S OF SOB SPO2 IS MAINTAINED AT 92% WITH 2L/MIN BY NC PT RESTING WELL IN CHAIR AT BEDSIDE AND CARRYING ON A CONVERSATIO N WITH HER CAREGIVER. NO COMPLAINS OF DISCOMFORT OR PAIN AT THIS TIME.

NURSING DX 2: ACTIVITY INTOLERANCE R/ T IMBALANCE BETWEEN OXYGEN SUPPLY AND DEMAND AEB PT ℅ WEAKNESS DURING WALKING TO WASHROOM

INTERVENTIONS: ENCOURAGE ADEQUATE REST PERIODS, ESPECIALLY BEFORE MEALS, ADL’S, EXERCISE SESSIONS AND AMBULATION- REST BETWEEN ACTIVITIES PROVIDES TIME FOR ENERGY CONSERVATION REFRAIN FROM PERFORMING NONESSENTIAL PROCEDURES- PT WITH LIMITED ACTIVITY TOLERANCE NEED TO PRIORITIZE TASKS ANTICIPATE PT’S NEEDS- KEPP TELEPHONE AND TISSUES WITHIN REACH ASSIST WITTH ADLS AS INDICATEDASSISTING THE PT WITH ADLS ALLOWS FOR CONSERVATION OF ENERGY. PROVIDE BEDSIDE COMMODE AS INDICATED- THIS REDUCES ENERGY EXPENDITURE PROGRESS ACTIVITY GRADUALLY, AS WITH THE FOLLOWING: ACTIVE ROM IN BED, PROGRESSING TO SITTING AND STANDING DANGLING 10 TO 15 MIN 3X DAILY DEEP BREATHING EXERCISES 3X DAILY SITTING UP IN CHAIR 30 MINUTES 3X DAILY WALKING IN ROOM 1 TO 2 MINUTES 3X DAILY WALKING IN HALL 25 FEET, THEN SLOWLY PROGRESSING, SAVING ENERGY FOR RETURN TRIP- THIS PREVENTS OVEREXERTING THE HEART AND PROMOTES ATTAINMENT OF SHORT RANGE GOALS. IMPROVISE IN ADAPTING ADL EQUIPMENT OR ENVIRONMENTAPPROPRIATE AIDS WILL ENABLE PT TO ACHIEVE OPTIMAL INDEPENDENCE FOR SELF- CARE.

GOALS: PT WILL AMBULATE 15 FT WITHOUT SOB BY THE END OF THE SHIFT 7A-1P

EVALUATION: PATIENT TOLERATES WELL AMBULATING TO THE WASHROOM (15FEET),AND ON THE RETURN TRIP TO THE CHAIR. PT USES WALKER AND CONTINUOUS O2 BY NC 2L/MIN TO AID IN AMBULATION AND MOST OF THE ADLS THAT SHE DOES BY HERSELF: TEETH CLEANING, FACE HYGIENE, FEEDING AND TOILETING.

NURSING DX 3: KNOWLEDG E DEFICIT R/ T DISEASE PROCESS AND TREATMENT AEB PATIENT NOT WEARING THE NC WITH O2 @ 2L/MIN DURING ADLS AND BECOMING SOB

INTERVENTIONS: EDUCATE PATIENT REGARDING: •S/S TO REPORT- CHEST PAIN, PALPITATIONS, WEAKNESS, DIZZINESS, SYNCOPE. •PRESCRIBED DIET •MEDICATIONS- NAME, DOSE, FREQUENCY, THERAPEUTIC EFFECTS, SIDE EFFECTS •ACTIVITY LEVELS •STRESS REDUCTION TECHNIQUESVISUALIZATION, BREATHING. USE ANATOMY DIAGRAMS AND HANDOUTS AS APPROPRIATE CARDIAC REHAB AS NEEDED SMOKING CESSATION EDUCATION AS NEEDED

GOALS: PATIENT WILL VERBALIZE REPORTABL E S/S BY THE END OF THE SHIFT 7A-1P

EVALUATION: PATIENT VERBALIZES S/S THAT MUST BE REPORTED TO THE PHYSICIAN: SOB AT REST WHEEZING OR CHEST TIGHTNESS AT REST NEED TO SIT IN CHAIR TO SLEEP WEIGHT CHANGE OF MORE THAN 5 POUNDS OVER OR UNDER NORMAL WEIGHT DIZZINESS, EXTREME FATIGUE OR FALLING

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