Nursing Care Plan

Problem Identified: Difficulty of breathing

Nursing Diagnosis: Ineffective breathing pattern related to decreased lung expansion secondary to surgery as evidenced by decreased respiratory depth.
Cause Analysis: Respiratory depression is the most serious adverse effect of opioid analgesics administered by IV, SubQ, or epidural routes. Specific notable changes are
decreasing respiratory rate or shallow respirations. (Brunner & Suddarth’s Medical Surgical Nursing, Page 190)

Cues Expected Outcome Nursing Interventions Rationale Evaluation

Objective: STO: Independent actions: Independent actions: STO:

Tachypnea: 26 breathes After 10 minutes of nursing
per minute intervention, the patient will be
Decreased respiratory able to decrease breathes per
depth minute from 26 to 12-20.
Cyanotic
LTO:
After 20 minutes of nursing
intervention, the patient will
establish normal breathing
pattern as evidenced by the
absence of cyanosis.
1. Administer oxygen at lowest 1. For management of underlying Goal met, the patient
concentration indicated and pulmonary condition, respiratory was able to decrease
prescribed respiratory medications. distress, or cyanosis. breathes per minute
2. Monitor pulse oximeter, as indicated. 2. To verify maintenance and from 26 to 12-20.
3. Suction airway, as needed. improvement in oxygen saturation.
4. Elevate head of bed, as appropriate. 3. To clear secretions. LTO:
5. Provide/encourage use of adjuncts, 4. To promote physiological ease of
such as incentive spirometer. maximal inspiration. Goal met, the patient
5. To facilitate deeper respiratory established normal
effort. breathing pattern as
evidenced by the
absence of cyanosis.

References: Nurse’s Pocket Guide Pages 151-155