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Patient Breathing Issues & Care Plan

The document contains 3 entries in a nursing care plan for a patient experiencing breathing difficulties. The first entry from October 26th notes the patient's symptoms of difficulty breathing, wheezing, and low oxygen saturation. The nurse assessed the patient's vital signs, provided oxygen therapy, medications, and positioning. The patient's breathing improved. The second entry from October 27th addressed the patient's ongoing cough. The nurse assessed the cough and lung sounds, maintained oxygen therapy, and educated the patient. Lung sounds were clear. The third entry from October 28th covered discharge planning. The nurse educated the patient on medications, follow-up, and the patient demonstrated understanding of the discharge plan.

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Soleil Maxwell
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22K views4 pages

Patient Breathing Issues & Care Plan

The document contains 3 entries in a nursing care plan for a patient experiencing breathing difficulties. The first entry from October 26th notes the patient's symptoms of difficulty breathing, wheezing, and low oxygen saturation. The nurse assessed the patient's vital signs, provided oxygen therapy, medications, and positioning. The patient's breathing improved. The second entry from October 27th addressed the patient's ongoing cough. The nurse assessed the cough and lung sounds, maintained oxygen therapy, and educated the patient. Lung sounds were clear. The third entry from October 28th covered discharge planning. The nurse educated the patient on medications, follow-up, and the patient demonstrated understanding of the discharge plan.

Uploaded by

Soleil Maxwell
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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MEJIA JEMIMAH A.

BSN3-F GROUP A

DATE AND TIME FOCUS DATA


October 26, 2020 Difficulty of Breathing  “I can’t breath, and it's going on for
7:30 am hours now” as verbalized by the client,
dyspnoeic, wheezing, coughing, rapid
irregular heart rate, tachypnea, VS: BP:
112/62 mm Hg, RR: 22, HR; 92,
irregular, temp: 36.5, Spo2: 87%.

A> Assessed vital signs of the client,


Monitored oxygen saturation,
Auscultated lung fields, Positioned
patient in a high fowlers, Administered
oxygen therapy as ordered,
Administered prescribed medications,
Encouarged patient to use relaxation
techniques.

R> “ I can now breath properly’ as


verbalized by the client, RR: 20 cpm
MEJIA JEMIMAH A.
BSN3-F GROUP A

DATE AND TIME FOCUS DATA


October 27, 2020 Cough  Received awake sitting on the bed
7:30 am with ongoing oxygen therapy per
nasal cannula at 2 L/minute. “ I have a
cough and it's already 2 weeks but ist
not going away” as verbalized by the
client, productive cough, thick
gelatinous sputum, dyspnea,
wheezing, RR:22, temp 37.5.

A> Auscultated lungs for the presence


of adventitious breath sounds,
Assessed for cough efficacy and
productivity, Assessed the
amount, quality, and color of the
sputum, Monitored respirations,
Positioned the patient in Semi
fowlers, Maintained humidified
oxygen as prescribed, Give
medications as prescribed,
Encouraged patient to increase
fluid intake to 3 liters per day,
Educated patient on coughing,
deep breathing, and splinting
techniques.

R> The patient has clear and open


airways as evidence by normal
breath sounds, normal rate and
depth of respiration,
MEJIA JEMIMAH A.
BSN3-F GROUP A

DATE AND TIME FOCUS DATA


October 28, 2020 Discharge plan  Received awake sitting on the bed, ‘ I
7:30 am think might go home, because the
doctor said that I should process my
papes because I'm now okay and
ready to go home’, normal vitals
signs, no distress or pain, appear to be
well.

A> Educated about the medications,


dosage, route, effect, and adverse
effect, Encourage to drink
medication in proper dosage and
time, Demonstrated the proper use
of metered-dose inhalers to the
patient, Instructed patients to
report to their primary healthcare
provider the changes and
consistent, prolonged periods of
dyspnea that are unrelieved by
medications, Instructed and
encouraged to attend follow up
check-up after 2 weeks of
discharge.

R> “ Yes I will go to my follow


up check up two weeks after my
discharge” as verbalized by the
patient, also demonstrated the
proper used of inhalers.
MEJIA JEMIMAH A.
BSN3-F GROUP A

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