Nursing diagnosis: May be related to Pain, Muscular impairment, Decreased energy and fatigue
Possibly evidenced by
Tachypnea, respiratory depth changes, reduced vital capacity
Holding breath, reluctance to cough
Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Establish effective breathing pattern.
Experience no signs of respiratory compromise or complications.
Nursing intervention with rationale:
1. Observe respiratory rate and depth.
Rationale: Shallow breathing, splinting with respirations, and holding breath may result in hypoventilation and atelectasis.
2. Auscultate breath sounds.
Rationale: Areas of decreased or absent breath sounds suggest atelectasis, whereas adventitious sounds reflect congestion.
3. Assist client to turn, cough, and deep-breathe periodically. Demonstrate how to splint incision. Instruct in effective breathing techniques.
Rationale: Promotes ventilation of all lung segments and mobilization and expectoration of secretions.
4. Elevate head of bed; maintain low-Fowler’s position. Support abdomen when coughing or ambulating.
Rationale: Facilitates lung expansion. Splinting provides incisional support and decreases muscle tension to promote cooperation with therapeutic regimen.
5. Assist with respiratory treatments, such as incentive spirometer.
Rationale: Maximizes expansion of lungs to prevent or resolve atelectasis.
6. Administer analgesics regularly or continuously by patientcontrolled analgesia (PCA), such as morphine sulfate, hydromorphone (Dilaudid), and ketorolac (Toradol).
Rationale: Facilitates movement and effective coughing, deep breathing, and activity.
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