Client Diagnosis: Shortness of breath, hypoxia

Assessment
Nursing Diagnosis (NANDA approved):
Nursing Diagnosis: Deficient Knowledge
r/t: emotional state affecting learning
A.E.B.: questioning members of the health care team
Complete Nursing Diagnosis Statement:
Client Centered Outcome: Pt. will describe rationale for treatment/therapy
Planning / Implementation

Interventions:
1. Consider the pts. ability to learn (eg; mental acuity, ability to see and year, existing
pain, emotional readiness, motivation, and previous knowledge.)
A. Rationale: Learning readiness changes over time based on situational,
physical and emotional challenges. The nurse assumes the role of authority, guide,
motivator, mentor, and consultant depending on the learning readiness of the pt.
(Ackley, pg. 504)
2. Assess personal context and meaning of illness (eg., perceived changes in lifestyle,
financial concerns, cultural patterns.)
A. Rationale: Improved symptom management and pt. satisfaction were noted
as a result of interventions that focused on the needs of the pt and the meaning and
perspective of their illness. (Ackley, pg. 505)
3. Repeat and reinforce information during several brief sessions.
A. Rationale: At times, the energy level of pts. may be diminished. Brief
sessions focus attention on essential information. Older pts. benefit from repeated
follow up sessons. (Ackley, pg. 506)
4. Use verbal and non-verbal therapeautic communication approaches including active
listening to encourage pt. to ask questions to gain the knowledge they are seeking
A. Rationale: A nurses communication skills contributes to the well being of pts.
and minimizes psychosocial problems. (Ackley, pg. 262)

Evaluation
Evaluation of Client Centered Outcome:



Assessment
Nursing Diagnosis (NANDA approved):
Nursing Diagnosis: Ineffective Breathing Pattern
r/t: hypoxia
A.E.B.: shortness of breath

Complete Nursing Diagnosis Statement:
Client Centered Outcome: Pt. O2 saturation will remain > 95 during shift.
Planning / Implementation

Interventions:
1. Auscultate breath sounds every 1 2 hours. Listen for diminished breath sounds,
crackles and wheezes.
A. Rationale: The presence of crackles and wheezes may alert the nurse to
airway obstruction, which may lead to or exacerbate existing hypoxia. (Ackley, pg. 375)
2. Monitor the clients behavior and mental status for the onset of restlessness, agitation
confusion, and (in the later stages) lethargy.
A. Rationale: Changes in behavior and mental status can be an early sign of
impaired gas exchange. (Ackley, pg. 175)
3. Monitor O2 sat continuosly using pulse oximetry.
A. Rationale: An oxygen saturation of < 90% indicates significant oxygenation
problems. . Pulse oximetry is a useful tool for tracking and/or readjusting or
supplementing oxygen. (Ackley, pg. 375)
4. Note use of accessory muscles, nasal flaring, retractions, irritability, confusion or
lethargy.
A. Rationale These symptos signal increasing respiratory signal increasing
respiratory difficulty and increasing hypoxia (Ackley, pg. 176)

Evaluation
Evaluation of Client Centered Outcome:
Goal partially met. Pts. O2 was 95 for most of the shift, but did go down to 94 at times.




Diagnostic
Test/Lab Test
Normal Value Pt. Value/
Implications of
value
Nursing Considerations/ Why
this test was needed for patient

Glucose


70 - 110
PV: 236 - 419

Imp: blood
sugar high and
not well
controlled
NC: Monitor bg frequently and
as per providers orders. Assess
for signs of hypoglycemia such as
increased thirst, vision changes,
polyuria, or changes in cognition.

Why: To administer proper dose
of insulin to pt.

Neutrophils


40 - 60


PV: 85

Imp: Value is
high pt. could
be developing
or trying to
stave off an
infection.
NC: Assess frequently for fever,
normal breath sounds, weakness
and fatigue and other signs of
infection.

Why: To determine if her SOB
may be caused by an infection.



Lymphocyte


20 - 40

PV: 0.8

Imp: Steroid
use is affecting
the low level
indicates
NC: Trend values by looking at
lab values every time they are
drawn to determine if value is
improving.

Why: To assess the pts. immune
immune system
compromised.
This puts pt. at
risk for
infection
function and ability to fight off
infection.



Echocardiogram


Structures all
functioning
appropriately
with no
abnormalies
present

PV: All views
within normal
limits nothing
of significance
to note

Imp: Ruled out
heart structures
causing the pts.
symptoms
NC: assure pt. study is painless.
Position pt. appropriately for
study to be performed accurately.

Why: To determine if structure
and function of the heart is within
normal limits to rule out
structural deficiencies causing
SOB and hypoxia pt. is
experiencing


EKG


Normal Sinus
Rhythm
PV: Premature
Ventricular
Contractons

Imp: abnormal
finding that
must be
investigated and
treated.

NC: Ensure leads are placed
appropriately to ensure accurate
reading., and that skin is clean
and dry so electrodes stay in
place.

Why: To assess electrical current
function and any abnormalies.




Patient Teaching Plan

Knowledge
Deficit r/t Pt.
educational
Need
Patient/Resident
Specific
Teaching
Content: Include
Specific
Instructions
Given and
Method of
Instructions
Patient/Resident
Strengths to
Learning
Patient/Resident
Barriers to
Learning
Evaluation of
Patient/Resident
Learning



























Medication Dose &
Route
Therapeutic Use and Side
Effects
Nursing Considerations &
Why was this medication
given to the
patient/resident?
Insulin
Detemir


20 units q hs
TU: lowers bg by moving
glucose into the cells

SE: hypoglycemia
NC: Insulin needs can
increase in a hospitalized pt

Why: To keep bg levels
within normal limits

Aspirin


81 mg q day

TU: propholactic use to as a
blood thinner

SE: seizures, coma, GI
bleeding,thrombocytopenia,
neutropenia, leukopenia
NC: Monitor AST, ALT
bilirubin, Bun, creatnine,
biliburbin. Also I & O

Why: Propholactically to
decrease chance of MI

Simvastatin


20 mg q hs

TU: reduces cholesterol
synthesis

SE: Liver dysfucntion,
pancreatitis, myositis,
rhabdomyolysis
NC: Liver dysfucntion,
pancreatitis, myositis,
rhabdomyolysis

Why: treatment for
hypercholesterolemia

Gabapentin




200 mg tid
po

TU: Neuropathic pain

SE: diplopia, leukopenia

NC: Assess for signs of
infection such as fever,
redness or swelling d/t risk
of leukopenia, assess for
mental status changes

Why: Diabetic nerve pain


Lovenox




40 mg q 24
hours sq

TU: Anti-coagulant,
prevention of DVTs


SE: bleeding, fever, edema
NC: Assess for signs of
bleeding, teach pt. to report
any unusual bleeding or
bruising immediately skin
assessment important

Why: Venous stasis d/t
immobility

Magnesium
Oxide



400 mg tid
po

TU: Increases osmotic
pressure, drawing fluid into
colon

SE: flaccid paralysis,
circulatory collapse
NC: Assess I & O, monitor
for signs of mag toxicity
such as thirst, confusion,
decrease in reflexes

Why: Arrhythmias

Allopurinol



100 mg q po

TU: reduces uric acid

SE: thrombocytopenia,
anemia, leukopenia, bone
marrow suppression
NC:

Why: Prophalactic tx of
gout