Nursing Care Plan | NCP Bariatric Surgery

Nursing diagnosis: ineffective Breathing Pattern related to Decreased lung expansion, Pain, anxiety, Decreased energy, fatigue, Tracheobronchial obstruction

Possibly evidenced by
Shortness of breath, dyspnea
Tachypnea, respiratory depth changes, reduced vital capacity
Wheezes, rhonchi
Abnormal arterial blood gases (ABGs)

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain adequate ventilation.
Experience no cyanosis or other signs of hypoxia, with ABGs within acceptable range.

Nursing intervention with rationale:
1. Monitor respiratory rate and depth. Auscultate breath sounds. Investigate presence of pallor and cyanosis, increased restlessness, or confusion.
Rationale: Respirations may be shallow because of incisional pain, analgesia, immobility, and obesity itself, causing hypoventilation and potentiating risk of atelectasis and hypoxia. Note: Many anesthetic agents are fat soluble, so the postoperative “resedation” and the potential for respiratory complications are increased.

2. Elevate head of bed 30 to 45 degrees.
Rationale: Encourages optimal diaphragmatic excursion and lung expansion and minimizes pressure of abdominal contents on the thoracic cavity. Note: When kept recumbent, obese clients
re at high risk for severe hypoventilation postoperatively.

3. Encourage deep-breathing exercises. Assist with coughing and splint incision.
Rationale: Promotes maximal lung expansion and aids in clearing airways, thus reducing risk of atelectasis and pneumonia. Note: Use of abdominal binder—properly fitted and placed at least 2 inches below the xiphoid process—can encourage deep breathing.

4. Turn periodically and ambulate as early as possible.
Rationale: Promotes aeration of all segments of the lung, mobilizing and aiding movement of secretions. Note: If client was a good candidate for bariatric surgery, she or he was probably relatively healthy before operation and is usually able to turn self, walk, and transfer to chair within 8 hours of surgery.

5. Pad side rails and teach client to use them as armrests.
Rationale: Using the side rail as an armrest allows for greater chest expansion.

6. Use small pillow under head, when indicated.
Rationale: Many obese clients have large, thick necks, and use of large, fluffy pillows may obstruct the airway.

7. Administer supplemental oxygen.
Rationale: Maximizes available O2 for exchange and reduces work of breathing.

8. Assist in use of blow bottle or incentive spirometer.
Rationale: Enhances lung expansion; reduces potential for atelectasis.

9. Monitor ABGs or pulse oximetry, as indicated.
Rationale: Reflects ventilation, oxygenation, and acid-base status. Used as a basis for evaluating need for and effectiveness of respiratory therapies.

10. Monitor patient-controlled analgesia (PCA) and administer analgesics, as appropriate.
Rationale: Maintenance of comfort level enhances participation in respiratory therapy and promotes increased lung expansion. Note: For the first 48 hours after the procedure, intravenous (IV) PCA is the method of choice. Oral medications are usually the next level of pain management.

Ineffective Breathing Pattern | Nursing Care Plan for Cholecystectomy

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.

risk for ineffective Breathing Pattern/Airway Clearance | Nursing Care Plan for Disc Surgery

Nursing diagnosis: risk for ineffective Breathing Pattern/Airway Clearance

Risk factors may include
Tracheal and bronchial obstruction or edema
Decreased lung expansion or pain

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Respiratory Status: Ventilation
Maintain a normal, effective respiratory pattern free of cyanosis and other signs of hypoxia, with arterial blood gases (ABGs) within acceptable range.

Nursing intervention with rationale
1. Inspect for edema of face and neck (cervical laminectomy), especially first 24 to 48 hours after surgery.
Rationale: Tracheal edema and compression or nerve injury can compromise respiratory function.

2. Listen for hoarseness. Encourage voice rest.
Rationale: Hoarseness may indicate laryngeal nerve injury or edema of surgical area, which can negatively affect cough and ability to clear airway.

3. Auscultate breath sounds. Note presence of wheezes or rhonchi.
Rationale: Abnormal breath sounds suggest accumulation of secretions or need to engage in more aggressive therapeutic actions to clear airway.

4. Assist with coughing, turning, and deep breathing. Encourage client’s use of incentive spirometry or other devices used to aid deep breathing.
Rationale: These maneuvers facilitate movement of secretions and clearing of lungs. They also reduce the risk of such respiratory complications as pneumonia, pulmonary embolus, and others.

5. Administer supplemental oxygen, if indicated.
Rationale: Supplemental oxygen may be necessary for periods of respiratory distress or evidence of hypoxia.

6. Monitor and graph ABGs or pulse oximetry.
Rationale: Monitors adequacy of breathing and oxygen therapy.

Ineffective Breathing Pattern | Nursing Care Plan for Ventilatory Assistance

Nursing diagnosis: ineffective Breathing Pattern/impaired Spontaneous Ventilation related to; respiratory center depression; respiratory muscle weakness or paralysis; noncompliant lung tissue (decreased lung expansion); alteration of client’s usual O2/CO2 ratio

Possibly evidenced by

Changes in rate and depth of respirations

Dyspnea and increased work of breathing, use of accessory muscles

Reduced VC and total lung volume

Tachypnea and bradypnea or cessation of respirations when off the ventilator

Cyanosis

Decreased PO2 and SaO2, increased PCO2

Increased restlessness, apprehension, and metabolic rate

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Reestablish and maintain effective respiratory pattern via ventilator with absence of retractions and use of accessory muscles, cyanosis, or other signs of hypoxia; ABGs and oxygen saturation within acceptable range.

Participate in efforts to wean (as appropriate) within individual ability.

Caregiver Will

Demonstrate behaviors necessary to maintain client’s respiratory function.

Nursing care plan intervention with rationale:

1. Investigate etiology of respiratory failure.

Rationale: Understanding the underlying cause of client’s particular ventilatory problem is essential to the care of client, for example, decisions about future capabilities and ventilation needs and most appropriate type of ventilatory support.

2. Observe overall breathing pattern. Note respiratory rate, distinguishing between spontaneous respirations and ventilator breaths.

Rationale: Client on a ventilator can experience hyperventilation, hypoventilation, or dyspnea and “air hunger” and attempt to correct deficiency by overbreathing.

3. Auscultate chest periodically, noting presence or absence and equality of breath sounds, adventitious breath sounds, and symmetry of chest movement.

Rationale: Provides information regarding airflow through the tracheobronchial tree and the presence or absence of fluid, mucous obstruction. Note: Frequent crackles or rhonchi

that do not clear with coughing or suctioning may indicate developing complications, such as atelectasis, pneumonia, acute bronchospasm, and pulmonary edema. Changes in chest symmetry may indicate improper placement of the ET tube or development of barotrauma.

4. Count client’s respirations for 1 full minute and compare with desired respirations and ventilator set rate.

Rationale: Respirations vary depending on problem requiring ventilatory assistance; for example, client may be totally ventilator dependent or be able to take breath(s) on own between ventilatordelivered breaths. Rapid client respirations can produce respiratory alkalosis and prevent desired volume from being delivered by ventilator. Slow client respirations and hypoventilation increases PaCO2 levels and may cause acidosis.

5. Verify that client’s respirations are in phase with the ventilator.

Rationale: Adjustments may be required in flow, tidal volume, respiratory rate, and dead space of the ventilator, or client may need sedation to synchronize respirations and reduce work of

breathing and energy expenditure.

6. Position client by elevating head of bed or chair if possible; place in prone position, as indicated.

Rationale: Elevating the client’s head and helping client get out of bed while still on the ventilator is both physically—helps decrease risk of aspiration—and psychologically beneficial. Note: Use of prone position is thought to improve oxygenation in client with severe hypoxic respiratory failure. However, it is not widely used due to the difficulties associated with placing and providing care to the intubated client in prone position as well as lack of studies showing its benefit in reducing mortality or duration of ventilation (Sud et al, 2008).

7. Inflate tracheal or ET tube cuff properly, using minimal leak and occlusive technique. Check cuff inflation every 4 to 8 hours and whenever cuff is deflated and reinflated.

Rationale: The cuff must be properly inflated to ensure adequate ventilation and delivery of desired tidal volume and to decrease risk of aspiration. Note: In long-term clients, the cuff may

be deflated most of the time or a noncuffed tracheostomy tube used if the client’s airway is protected.

8. Check tubing for obstruction, such as kinking or accumulation of water. Drain tubing as indicated, avoiding draining toward client or back into the reservoir.

Rationale: Kinks in tubing prevent adequate volume delivery and increase airway pressure. Condensation in tubing prevents proper gas distribution and predisposes to bacterial growth.

9. Check ventilator alarms for proper functioning. Do not turn off alarms, even for suctioning. Remove from ventilator and ventilate manually if source of ventilator alarm cannot be quickly identified and rectified. Ascertain that alarms can be heard in the nurses’ station.

Rationale: Ventilators have a series of visual and audible alarms, such as oxygen, low volume or apnea, high pressure, and inspiratory/ expiratory (I:E) ratio. Turning off or failure to reset

alarms places client at risk for unobserved ventilator failure or respiratory distress or arrest.

10. Keep resuscitation bag at bedside and ventilate manually whenever indicated.

Rationale: Provides or restores adequate ventilation when client or equipment problems require client to be temporarily removed from the ventilator.

Ineffective Breathing Pattern | Nursing Care Plan for Pneumothorax

Nursing diagnosis: ineffective breathing pattern related to decreased lung expansion due to air or fluid accumulation; musculoskeletal impairment; pain and anxiety; inflammatory process

Possibly evidenced by

Dyspnea, tachypnea

Changes in depth or equality of respirations; altered chest excursion

Use of accessory muscles, nasal flaring

Cyanosis, abnormal ABGs

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Establish a normal and effective respiratory pattern with ABGs within client’s normal range.

Be free of cyanosis and other signs or symptoms of hypoxia.

Nursing intervention with rationale:

1. Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.

Rationale: Understanding the cause of lung collapse is necessary for proper chest tube placement and choice of other therapeutic measures.

2. Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.

Rationale: Respiratory distress and changes in vital signs occur because of physiological stress and pain or may indicate development of shock due to hypoxia or hemorrhage.

3. Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.

Rationale: Difficulty breathing with ventilator or increasing airway pressures suggests worsening of condition and development of complications, such as spontaneous rupture of a bleb creating

a new pneumothorax.

4. Auscultate breath sounds.

Rationale: Breath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed areas have decreased sounds. Regularly scheduled evaluation also helps determine areas of good air exchange and provides a baseline to evaluate resolution of pneumothorax.

5. Note chest excursion and position of trachea.

Rationale: Chest excursion is unequal until lung reexpands. Trachea deviates from affected side with tension pneumothorax.

6. Assess fremitus.

Rationale: Voice and tactile fremitus (vibration) is reduced in fluid-filled or consolidated tissue.

7. Assist client with splinting painful area when coughing, or during deep breathing.

Rationale: Supporting chest and abdominal muscles makes coughing more effective and less traumatic.

8. Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible.

Rationale: Promotes maximal inspiration; enhances lung expansion and ventilation in unaffected side.

9. Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.

Rationale: Assists client to deal with the physiological effects of hypoxia, which may be manifested as anxiety or fear.

Nursing Diagnosis for Cardiac Surgery | Ineffective Breathing Pattern

Nursing diagnosis: risk for ineffective breathing patter.

Risk factors may include

Inadequate ventilation (pain, muscular weakness)

Diminished oxygen-carrying capacity (blood loss)

Decreased lung expansion (atelectasis or pneumothorax and hemothorax)

Possibly evidenced by

(Not applicable; presence of signs and symptoms establishes an actual diagnosis.)

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

Maintain an effective respiratory pattern free of cyanosis and other signs and symptoms of hypoxia, with breath sounds equal

bilaterally, lung fields clearing.

Display complete reexpansion of lungs with absence of pneumothorax and hemothorax.

Nursing care plan intervention with rationale:

1. Evaluate respiratory rate and depth. Note respiratory effort, for example, presence of dyspnea, use of accessory muscles, and nasal flaring.

Rationale: Client responses are variable. Rate and effort may be increased by pain, fear, fever, diminished circulating volume due to blood or fluid loss, accumulation of secretions, hypoxia, or gastric distention. Respiratory suppression can occur from long time period under anesthesia, or heavy use of opioid analgesics. Early recognition and treatment of abnormal ventilation may prevent complications.

2. Auscultate breath sounds. Note areas of diminished or absent breath sounds and presence of adventitious sounds, such as crackles or rhonchi.

Rationale: Breath sounds are often diminished in lung bases for a period of time after surgery because of normally occurring atelectasis. Loss of active breath sounds in an area of previous ventilation may reflect collapse of the lung segment, especially if chest tubes have recently been removed. Crackles or rhonchi may be indicative of fluid accumulation due to interstitial edema, pulmonary edema, or infection, or partial airway obstruction with pooling of secretions.

3. Observe chest excursion. Investigate decreased expansion or lack of symmetry in chest movement.

Rationale: Air or fluid in the pleural space prevents complete expansion (usually on one side) and requires further assessment of ventilation status.

4. Observe character of cough and sputum production.

Rationale: Frequent coughing may simply be throat irritation from operative endotracheal tube (ET) placement or can reflect pulmonary congestion. Purulent sputum suggests onset of

pulmonary infection.

5. Inspect skin and mucous membranes for cyanosis.

Rationale: Cyanosis of lips, nail beds, or earlobes, or general duskiness may indicate a hypoxic condition due to heart failure or pulmonary complications. General pallor, commonly present in immediate postoperative period, may indicate anemia from blood loss or insufficient blood replacement or RBC destruction from CPB pump.

6. Elevate head of bed, place in upright or semi-Fowler’s position. Assist with early ambulation and increased time out of bed.

Rationale: Stimulates respiratory function and lung expansion. Effective in preventing and resolving pulmonary congestion.

7. Encourage client participation in and responsibility for deepbreathing exercises, use of adjuncts, and coughing, as indicated.

Rationale: Aids in lung reexpansion and maintaining patency of small airways, especially after removal of chest tubes. Coughing is not necessary unless wheezes and rhonchi are present,

indicating retention of secretions.

8. Reinforce splinting of chest with pillows during deep breathing or coughing.

Rationale: Reduces incisional tension, promotes maximal lung expansion, and may enhance effectiveness of cough effort.

9. Explain that coughing and respiratory treatments will not loosen or damage grafts or reopen chest incision.

Rationale: Provides reassurance that injury will not occur and may enhance cooperation with therapeutic regimen.

10. Encourage maximal fluid intake within cardiac reserves.

Rationale: Adequate hydration helps liquefy secretions, facilitating expectoration.

11. Medicate with analgesic before respiratory treatments, as indicated.

Rationale: Allows for easier chest movement and reduces discomfort related to incisional pain, facilitating client cooperation with and effectiveness of respiratory treatments.

12. Record response to deep-breathing exercises or other respiratory treatment, noting breath sounds before and after treatment, as well as cough and sputum production.

Rationale: Documents effectiveness of therapy or need for more aggressive interventions.

13. Investigate and report respiratory distress, diminished or absent breath sounds, tachycardia, severe agitation, and drop in BP.

Rationale: Although not a common complication, hemothorax or pneumothorax may occur following removal of the chest tubes and requires prompt intervention to maintain respiratory function.