Nursing Care Plan for Elderly Woman with Shortness of Breath

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Nursing Care Plan for Elderly Woman with Shortness of Breath

Patient Demographics

Student: ______ Clinical Site: _________ Date: __________________

Client Initials: __E.D.__ Age: __65_______ Weight: _75.7 kg Height: ___69________in.

Primary Language:_English____ Religion: _LDS, active in church__ Culture: __Retired lives with daughter and son-on law, they are at the bedside off and on throughout the day____________________

Admitting Diagnosis: ___Pneumoia_________________________________________________________

Secondary Diagnosis: __Hypoxia___________________________________________________________

Allergies & Reactions: __No Allergies_______ Code Status: DNR_____ Physician:__Chandler________

History of Present Illness (Please include a detailed description of the present illness including past medical and surgical history-paint a picture) What brought your client to this facility?
Mrs. D is 65 year old Caucasian female presents in the ED for shortness of breath and difficulty taking deep breaths. Past medical hx includes depression, anxiety and MS. Past surgical history includes hernia repair. Patient reports she has 4 children and 3 of them live in other states. Her daughter that lives locally is her primary caregiver. Patient does not smoke “quit 20 years ago and smoked 1 pack a day for 15 years” and she does not drink. She was admitted to the facility 8/4/14 for pneumonia and hypoxia. Patient is unable to take care for self she requires assistance with ADL’s. Patient reports that when she takes a deep breath in, has pain on the right side. Has unproductive cough, decreased lung sounds in all lung fields. Unable to get adequate sleep because of Shortness of breath. Ego integrity vs despair stage of development. Alert and oriented x’s 3. Patient is forgetful when family is in the room. Mood appropriate.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Orders/Treatments (include cares/procedures ordered for the patient except for med and labs)
Monitor Vital signs every 4 hours, O2 @ 6 lpm NC to keep O2 above 90%. Can switch to re-breather mask if oxygen saturation requirement is not met. Antibiotics. Telemetry.
Pathophysiology (Include Pathophysiology of the presenting diagnosis at the cellular level – not procedure or surgery –Include treatments as well as relating your “text book” picture to your patient).
Pneumonia- Microorganisms enter the alveolar spaces by droplet inhalation, inflammation occurs, and alveolar fluid increases. As a result, gas exchange is impaired and ventilation decreases as secretions thicke Pneumonia has caused an infection of the lungs. The lungs are made up of small sacs called alveoli, which fill with air when a healthy person breathes. When an individual has pneumonia, the alveoli are filled with pus and fluid, causing fluid into the alveoli causing disruption in gas exchange, which makes breathing painful and limits oxygen intake (Lewis, 2011).(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Hypoxia reduction in PO2 below the normal range, regardless of whether gas exchange is impaired in the lung, it is a pathological condition in which the body as a whole or a region of the body is deprived of adequate oxygen supply. When an individual has pneumonia the patient has limited gas exchange which results in hypoxia (Lewis, 2011).(Nursing Care Plan for Elderly Woman with Shortness of Breath)

Physical Assessment

Body SystemsActual or Potential Nursing Diagnosis
General Appearance: 65 year old woman, appears older than stated age 
Vital Signs:
B/P 128/78 L arm sitting
Temp: 99.5 F
Tympanic Pulse: 72 bpm
Respiration: 18 bpmOximetry: 94 % on 6 lpm n/c
Pain Assessment: reports no pain currently. Often has pain 4/10 when coughing. Dull pain that is relieved by sitting up in bed.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Ineffective breathing pattern r/t pneumonia

Activity intolerance r/t imbalance between oxygen supply and demand.
HEENT:
Inspect Head: No Lesions presentVisual Acuity Wears corrective lenses
Hearing acuity: No evidence of hearing aids, patient responds to whisper test.
Nose: Mucosa is pink and moist. Septum is midline. Nares are patent with no drainage
Mouth/Throat: Trachea is midline. Patient wears dentures upper and lower. Oral mucosa is pink, moist with no lesions.Lymph nodes non palpable.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
 
Neurological:Orientation: Alert and oriented X’s 3 when in the room alone. When family is in the room the patient is forgetful and often oriented only to self. No acute signs of distress, patient canfollow verbal commands

PERRLA
Gross Motor sensation is present in all extremitiesSwallow: Gag reflex not assessed, but patient swallows without difficultyCranial Nerves: See previous body systems(Nursing Care Plan for Elderly Woman with Shortness of Breath)
 
Respiratory:
Breathing inspection:Respirations 18/min, shallow and even
Breath Sounds:Decreased coarse breath sounds auscultated over all lobes
Chest expansion symmetric, mildrefractions. No pain or tenderness on palpation. Pain on inspiration
Cough:non-productive cough present
Oxygen therapy:94% on 6L/min
Skin Color:pink, intact, no edema
Impaired gas exchange
Cardiovascular:
Edema: No edema present
Pulses- Apical 72 bpm regular rhythm, all other pulses 2+ strong bilateralAuscultation: S1 and S2 auscultated. Carotid pulse equal bilateral, no bruits auscultated. Regular rate and rhythm without murmurs.Capillary Refill: < 3 seconds in hands and feet(Nursing Care Plan for Elderly Woman with Shortness of Breath)
 
Gastrointestinal:
Inspect abdomen: Soft, non-tender, non-distended upon palpitation. Skin of abdomen free of lesions and rashes.
Bowel sounds x4: Active Bowel sounds in all 4 quadrants.
Last BM: Last BM was today, normal consistency, patient is in a brief but will ask to go to the bathroom.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Diet/Appetite : Mechanical soft diet, needs assistance to eat. Ate 50% of meals today.
Imbalanced nutrition: Less than body requirements related to inability to eat on own
Genitourinary:
Catheters: 18 French catheter
Quality of Urine: Dark amber urine
Continence: incontinent.Voiding Frequency Urgency: without urgency
Painful: denies painful urination(Nursing Care Plan for Elderly Woman with Shortness of Breath)
 
Musculoskeletal:
ROM, strength upper & lower extremities: Limited ROM in lower extremities. Full ROM in upper extremities. Wheelchair bound
Activity Level: Up to chair with assistance.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Gait: uneven gait. Will stand and shuffles to try walk.
 
Integumentary:
Skin: pink, warm to touch, turgor rapid recoil,no edema, cyanosis, or clubbing
Drains, drainage, dressing: 18 g LEJ ½ NS @ 50cc. Dressing clean, dry intact without redness or swelling. No other dressings or drains noted
Pressure Points: Braden scale 14 high risks. Morse fall scale 28 high risk
 
Emotional/Psychological: 
Anxious, angry etc: Patient is very pleasant when she is alone. Appears anxious when family is in the room with her.
Appropriate: Appropriate to situation
Sleep Patterns: Altered sleep patterns, patient is restless. Nurse reports patient only slept 3 hours last night. Patient states “I am very tired.”
Erickson’s developmental stage: Ego vs. Despair(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Impaired comfort r/t hospitalizationAnxiety related to change in health status

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LABS

Lab TestPatient ValueAdmit CurrentNormal RangeRationale for Abnormal (apply this to YOUR patient)
CBC  
RBC  4.1-6.0 
Hgb 11.0 (l)12-18g/dLLow related to pneumonia and decreased oxygenation (Pagana, 2010)
Hct 33.0 (l)38-48%Low related to pneumonia and decreased oxygenation (Pagana, 2010)(Nursing Care Plan for Elderly Woman with Shortness of Breath)
WBC 8.05.0-10.0 
Neutrophils 56.455-70% 
Lymphocytes 28.020-35% 
Monocytes 4.23-8% 
Eosinophils 1.51-3% 
Basophils 0.70.5-1% 
Bands  0-11% 
Platelets 210150-400 
CMP  
Na+ 143135-146mEq/L 
K+ 2.6 (l)3.5-5.1mEq/LLow due to dehydration or other electrolyte imbalance (Pagana, 2010)
Cl- 10895-105mEq/L 
CO2 3024-32mEq/L 
Glucose 10360-110mg/dL 
BUN 136-20mg/dL 
Creatinine .70.6-1.4mg/dL 
Calcium 9.28.5-10.5mg/dL 
Total Protein 6.16.0-8.0g/dL 
Albumin 3.93.5-5.0g/dL 
Alk Phos 9038-126 U/L 
ALT 1110-35 U/L 
AST 158-38 U/L 
GGT  4-23 U/L 
Phosphorus  3.0-4.5 mg/dL 
Magnesium  1.3-2.5mEq/L 
CRP  <0.8 
ESR  0-20mm/hour 
PTINR  9.5-12 sec1.0 (normal)2.0-3.0 (therapeutic) 
PTT  20-45 sec 
LIVER  
Total Bilirubin  0.1-1.0 mg/dL 
Direct Bilirubin  0.0-0.4 mg/dL 
Indirect Bilirubin  0.4-1.0 bg/dL 
Ammonia  15-45mcg/dL 
CARDIAC  
Total Cholesterol  140-200 mg/dL 
LDL  60-160 mg/dL 
HDL  29-77 mg/dL 
Triglycerides  40-190 mg/dL 
CK  25-200 U/L 
CK-MB  0-7 U/L 
Troponin  <0.4 
BNP  <100 pg/mL 
GASTROINTESTINAL  
Amylase  56-190 U/L 
Lipase  0-110 U/L 
H. pylori  Negative 
Stool Occult Blood  Negative 
ENDOCRINE  
TSH  0.5-5.5uU/mL 
T3  800-200ng/dL 
T4  4-12ng/dL 
Hgb A1c  4-7% 
RESPIRATORY  
ABG    
pH  7.35-7.45 
pO2  80-100mmHg 
pCO2  35-45mmHg 
HCO3  22-26mEq/L 
URINALYSIS  
pH  4.6-8.0 
Specific Gravity  1.01-1.025 
Protein  Negative 
Glucose  Negative 
Ketones  Negative 
Bilirubin  Negative 
Nitrites  Negative 
Leukocyte esterase  Negative 
WBC  0-5/hpf 
RBC  0.4/hpf 
Casts  None to occasional 
CULTURES  
Urine  No Growth 
Stool  No Growth 
Wound  No Growth 
Blood  No Growth 
Sputum  No Growth 
     

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Nursing Care Plan for Elderly Woman with Shortness of Breath
Nursing Care Plan for Elderly Woman with Shortness of Breath

DIAGNOSTIC TESTS

DIAGNOSTIC TESTDATEPATIENT’S TEST RESULTS AND RATIONALE
EKG  
X-RAY8/4/14CXR single view. Low lung volumes are present. No pneumothorax. Bilateral lower lobe pneumonia
ULTRASOUND  
CAT SCAN MI  
ULTRASOUND  
CARDIAC CATHETERIZATION  
ECHO  
VENOUS DOPPLER  
BRONCHOSCOPY  
BIOPSIES  
SCOPES (EX. Colonoscopy)  
LUMBAR PUNCTURE  
EEG  
Other:  

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MEDICATIONS

Drug /Trade & generic /ClassDosage/route/scheduleReason for UseNursing Consideration
Levaquin/LevofloxacinAnti-infective broad spectrum antibiotic that inhibits DNA into bacteria750 mg PO dailyTreatment of pneumoniaObtain C & S prior to therapy, Assess for previous allergic reaction, monitor I & O, assess for diarrhea (Skidmore-Roth, 2013).(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Enoxaprin/LovenoxLow molecular heparin with antithrombotic properties40 mg SC dailyPrevention of clotsAssess coagulation studies, monitor bleeding (Skidmore Roth, 2013).(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Tylenol625 mg Q4hrs prnPain or feverMonitor for S&S of: hepatotoxicity , Do not take other medications containing acetaminophen without medical advice (Skidmore Roth, 2013)(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Prozac/fluoxetine hydrochlorideelective serotonin reuptake inhibitor40 mg PO dailyDepressionUse with caution in the older adult patient, lab tests: periodic serum electrolytes; monitor closely plasma glucose in diabetes, serum sodium level, weigh weekly to monitor weight loss (Skidmore Roth, 2013).
Xanax/alprazolam benzodiazepine1 mg PO prnanxietyAssess anxiety, Monitor BP, Monitor hepatic function and CBC with long time use. Assess mental status (Skidmore Roth, 2013).(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data(AEB or Risk Factors)
Goals (SMART)
1-Short term goal (STG)1-Long term goal (LTG)(Specific, Measurable, Attainable, Realistic, Time frame)
Interventions
3 for each diagnosis:assess, monitor, teach/educate, etc.(Must also include frequency)
Rationale
Give one reason for each nursing intervention that is performed.
Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.
# 1.Impaired gas exchange r/t inadequate airway and alveolar clearance secondary to pneumonia, aeb decreased coarse breath sounds and shortness of breath (Ackley, 2012).Patient will demonstrate the use of incentive spirometer 10 times every hour by 1 pm.
Patient will remain free of respiratory distress and maintain clear lung fields throughout the shift.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Assess LOC and distress.Monitor respiratory rate and depth and ease of breathing. Watch for use of accessory muscles and nasal flaring.

Teach how to use incentive spriometer and deep breathing exercises.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
May indicate worsening hypoxia.Indicates if there is a change in respiratory status.

Helps open up the airway for ventilation and keeps alveoli open.
Patient is using incentive spirometer, patient is partially meeting goals.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data(AEB or Risk Factors)
Goals (SMART)
1-Short term goal (STG)1-Long term goal (LTG)(Specific, Measurable, Attainable, Realistic, Time frame)
Interventions
3 for each diagnosis:assess, monitor, teach/educate, etc.(Must also include frequency)(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Rationale
Give one reason for each nursing intervention that is performed.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.
# 2.Ineffective breathing pattern r/t pneumonia aeb SOB, shallow breathing, and decreased oxygen saturation levels (Ackley, 2012).Patient will be able to verbalize understanding of proper deep breathing techniques by 1 pm.Patient will establish normal breathing patterns by discharge.Assess respiration rate, rhythm, and depth.Monitor deep inspirations to increase oxygenation.

Teach appropriate deep breathing, and coughing techniques.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Early signs of respirator difficulties.Increase oxygenation.

Clears secretions.
Patient is working on deep breathing. Patient demonstrates understanding of deep breathing and coughing to clear lungs.

Goals are partially being met at this time.
Nursing Diagnosis
Supported by 3 subjective and/or objective assessment data(AEB or Risk Factors)
Goals (SMART)
1-Short term goal (STG)1-Long term goal (LTG)(Specific, Measurable, Attainable, Realistic, Time frame)
Interventions
3 for each diagnosis:assess, monitor, teach/educate, etc.(Must also include frequency)
RationaleGive one reason for each nursing intervention that is performed.Evaluation
Is the STG and LTG met, partially met, not met? Explain progress.
 # 3.Impaired comfort r/t hospitalization aeb restlessness, disturbed sleeping patterns, and confusion (Ackley, 2012).Identify strategies to improve or maintain comfort by 10 am.Maintain an acceptable level of comfort throughout shift.Assess patients current level of comfort.

Enhance feelings between the patient and those providing care.

Offer suggestions for improving comfort by breathing to relax and utilize empathy in response to patient’s negative emotions.(Nursing Care Plan for Elderly Woman with Shortness of Breath)
Identifies baseline for patient.To attain the highest comfort, patient must trust those providing care.

Helps patient to identify strategies that work for her.

Empathy also promotes trust.
Patient is developing trust with the hospital staff.

However, when family is present patient does not speak up.

Goals are not being met currently.

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Nursing Care Plan for Elderly Woman with Shortness of Breath
Nursing Care Plan for Elderly Woman with Shortness of Breath

References

Ackley, B. J. &Ladwig, G. B. (2014). Nursing diagnosis handbook: An evidence-based guide to planning care. (10th ed.). St. Louis, MO: Mosby Elsevier.

Jordan Valley Hospital, Electronic medical records, West Jordan UT.

Lewis, S.,Heitkemper, M., Dirksen, S., O’Brien, P., & Bucher, L. (2010). Medical-surgical nursing: Assessment and management of clinical problems (8th ed.). St. Louis, MO: Mosby-Elsevier.

Pagana, KathleenDeska,Pagana, Timothy J. (2010). Mosby’s Manual of Diagnostic and Laboratory Tests (4thed). St. Louis, MO: Mosby Elsevier.

Skidmore-Roth, Linda, (2012) Mosby’s Drug Guide for Nurses, with 2012 Update: 9th Edition

Related FAQs

1. How can nurses help patients with shortness of breath?

Patients who suffer from the shortage of breath will need support and care from nurses, thus, building a level of trust between nurses and patients. Much attention and assessment of systemic observation permit the nurse to offer an understanding of how patients manage their health condition.

2. What are the nursing interventions for ineffective breathing pattern?

The following are the therapeutic nursing interventions for ineffective breathing pattern: Place patient with proper body alignment for maximum breathing pattern. A sitting position permits maximum lung excursion and chest expansion. These techniques promotes deep inspiration, which increases oxygenation and prevents atelectasis.

3. Is nursing intervention for the shortage of breath overrated?

Nursing Intervention for the shortage of breath has thus proven to be most helpful in the advancement of victims of a shortage of breath and, therefore, should not be underrated. Patients are more likely to improve with the support and help from nurses.

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