This article covers a sample 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 Systems | Actual 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 Test | Patient ValueAdmit Current | Normal Range | Rationale for Abnormal (apply this to YOUR patient) | |
| CBC | ||||
| RBC | 4.1-6.0 | |||
| Hgb | 11.0 (l) | 12-18g/dL | Low 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 | 8.0 | 5.0-10.0 | ||
| Neutrophils | 56.4 | 55-70% | ||
| Lymphocytes | 28.0 | 20-35% | ||
| Monocytes | 4.2 | 3-8% | ||
| Eosinophils | 1.5 | 1-3% | ||
| Basophils | 0.7 | 0.5-1% | ||
| Bands | 0-11% | |||
| Platelets | 210 | 150-400 | ||
| CMP | ||||
| Na+ | 143 | 135-146mEq/L | ||
| K+ | 2.6 (l) | 3.5-5.1mEq/L | Low due to dehydration or other electrolyte imbalance (Pagana, 2010) | |
| Cl- | 108 | 95-105mEq/L | ||
| CO2 | 30 | 24-32mEq/L | ||
| Glucose | 103 | 60-110mg/dL | ||
| BUN | 13 | 6-20mg/dL | ||
| Creatinine | .7 | 0.6-1.4mg/dL | ||
| Calcium | 9.2 | 8.5-10.5mg/dL | ||
| Total Protein | 6.1 | 6.0-8.0g/dL | ||
| Albumin | 3.9 | 3.5-5.0g/dL | ||
| Alk Phos | 90 | 38-126 U/L | ||
| ALT | 11 | 10-35 U/L | ||
| AST | 15 | 8-38 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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DIAGNOSTIC TESTS
| DIAGNOSTIC TEST | DATE | PATIENT’S TEST RESULTS AND RATIONALE |
| EKG | ||
| X-RAY | 8/4/14 | CXR 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: |
Related Content: Nursing Plan of Care Concept Map
MEDICATIONS
| Drug /Trade & generic /Class | Dosage/route/schedule | Reason for Use | Nursing Consideration |
| Levaquin/LevofloxacinAnti-infective broad spectrum antibiotic that inhibits DNA into bacteria | 750 mg PO daily | Treatment of pneumonia | Obtain 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 properties | 40 mg SC daily | Prevention of clots | Assess coagulation studies, monitor bleeding (Skidmore Roth, 2013).(Nursing Care Plan for Elderly Woman with Shortness of Breath) |
| Tylenol | 625 mg Q4hrs prn | Pain or fever | Monitor 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 inhibitor | 40 mg PO daily | Depression | Use 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 benzodiazepine | 1 mg PO prn | anxiety | Assess 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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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.
