ACUTE BRONCHITIS

Assessment Patient has O saturation below

2

7
Nursing Diagnosis Ineffective Airway Clearance related to disproportionate, thickened mucous discharge, as evidenced by presence of rhonchi, tachypnea, and ineffective cough (Doenges, Moorhouse & Murr, 2006) Goals The patient will no show signs and symptoms of difficulty in breathing, and will remain above 92% oxygen saturation (Swearingen, 2011). 1. Intervention/ Rationale Place patient laterally and recumbent to help maintain an open airway (Swearingen, 2011). Apply oxygen merely if it helps the patient to decrease her laboured respirations (Swearingen, 2011). Observe the oxygen therapy delivery system, every hour, to gauge if the equipment is set up appropriately on the patient as per doctors orders (Swearingen, 2011). Evaluation The patient states that her pain level has dropped from a 7/10 to a 2/10. The patients oxygen saturation levels remain above 95% for the duration of nurses shift. The nasal cannula remains properly inserted in the nares.

92% as measured by the pulse oximetry. When the patient coughs, sputum with a 1cm circumference is expelled. The patient exhibits rapid, painful breathing as indicated by pain of 7/10 (Swearingen, 2011).

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The patient reports restlessness and a sensation of chest contraction. Respirations are rapid and superficial, with use of accessory muscles (Haugen & Galura, 2010).

Impaired Respiratory Function related to ineffective breathing pattern, as evidenced by increased respiratory rate (Haugen & Galura, 2010).

The patient will sustain sufficient respiratory function as evidenced by enhancement of breath sounds, decreased rate of respirations and arterial blood gas volumes in a normal range for patient (Haugen & Galura, 2010).

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The patient reports an inability to fall asleep due to high pain level (7/10) and difficulty and pain associated with laying in a certain direction (Doengest et al., 2006). When patient is asked to cough, she reports a sharp, stabbing feeling which is brought upon during the inhalation prior to coughing, and during coughing (Doengest et al., 2006).

Acute Pain related to inflammation of the lungs , persistent cough, pain associated with fever, as evidenced by reports of discomfort, and facial expression associated with pain (Doengest et al., 2006).

The patient will decrease pain level from a 7/10 to a 2/10 by the end of nurses 12 hours hospital shift using appropriate breathing and medication techniques (Doengest et al., 2006).

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Always stay with patient when she is having difficulties breathing, to reduce anxiety, and further tachypnea (Haugen & Galura, 2010). Demonstrate diaphragmatic and purse lip breathing to patient to assist with slowing the respiratory rate, and and reduce air trapping (Haugen & Galura, 2010). Sustain the patients fluid intake to a minimum of 2,500mL po or IV, per day, to help encourage breakdown of secretions and lessen dryness in respiratory mucous membrane (Haugen & Galura, 2010). Administer acetaminophen pain medication q4-6h to manage and prevent breakthrough pain (Swearingen, 2011). Monitor vitals sign qh for respiratory suppression and hypoventilation associated with pain medications (Swearingen, 2011). Help patient increase level of comfort in hospital bed by elevating the head of the bed, to help assist in proper, less painful breathing, and provide client with pillow to hug when coughing (Doengest et al., 2006).

The patient states feeling les stressed and worried when she is having difficulty in breathing, leading to a decrease in tachypnea. The patient was able to practice diaphragmatic and purse lip breathing, also helping to reduce respirations and improve gas exchange. Through bottled water, the patient was able to consume 2,500 mL of water in a 24 hours period, with an outtake of 1,400 cc of hay coloured urine in the same time period. The fluid helped reduce the thickness of the phlegm and helped relieve throat dryness. The patient was able to take her pain medication q6h, which helped to reduce her pain level to a 2/10, which was maintained for the duration of the shift. The vital signs remained within a normal range (respirations = 16), and the temperature was able to decrease slightly (37 degrees). The patient was able to re-position herself in bed to help achieve a proper comfort level and was able to use pillow to control pain when coughing.

ACUTE BRONCHITIS