1. The patient, Ms. GT, was admitted to a care facility due to inability to care for herself. She has a history of obstructive sleep apnea and uses a CPAP machine.
2. The nursing assessment found impaired breathing patterns related to sleep apnea, as evidenced by breaks in breathing and shallow breathing during sleep.
3. The nursing plan is to monitor vital signs, encourage side-lying sleep position, use of CPAP machine, head elevation, and respiratory muscle training to improve breathing patterns and oxygen levels.
1. The patient, Ms. GT, was admitted to a care facility due to inability to care for herself. She has a history of obstructive sleep apnea and uses a CPAP machine.
2. The nursing assessment found impaired breathing patterns related to sleep apnea, as evidenced by breaks in breathing and shallow breathing during sleep.
3. The nursing plan is to monitor vital signs, encourage side-lying sleep position, use of CPAP machine, head elevation, and respiratory muscle training to improve breathing patterns and oxygen levels.
1. The patient, Ms. GT, was admitted to a care facility due to inability to care for herself. She has a history of obstructive sleep apnea and uses a CPAP machine.
2. The nursing assessment found impaired breathing patterns related to sleep apnea, as evidenced by breaks in breathing and shallow breathing during sleep.
3. The nursing plan is to monitor vital signs, encourage side-lying sleep position, use of CPAP machine, head elevation, and respiratory muscle training to improve breathing patterns and oxygen levels.
1. The patient, Ms. GT, was admitted to a care facility due to inability to care for herself. She has a history of obstructive sleep apnea and uses a CPAP machine.
2. The nursing assessment found impaired breathing patterns related to sleep apnea, as evidenced by breaks in breathing and shallow breathing during sleep.
3. The nursing plan is to monitor vital signs, encourage side-lying sleep position, use of CPAP machine, head elevation, and respiratory muscle training to improve breathing patterns and oxygen levels.
ACTION RATIONALE Nursing Assessment: 1.Ineffective 1.After 24 hours 1.Assess resident vital signs -To assist in creating an Goal Meet: Ms. GT is a 77-year-old retired Breathing of nursing and characteristic of accurate diagnosis and After 24 hours of elementary teacher. She was Patterns related intervention. The respiration at least every 4 monitor effectiveness of evaluation the admitted voluntarily on March to impaired patient will hours medical treatment. resident respiratory 12, 2021, at Kiwanis Home regulation achieve effective rate is 18bpm, it is care facility due to unable to secondary to breathing 2.Encourage the resident -Sleeping on one’s back within the normal care herself. Ms. GT has a sleep apnea as patterns as to sleep in side-lying increase the chance of range, O2 Sat 96% on short-term memory problem evidence by evidence by position and avoid supine throat muscle to relax room air and but had the ability to break in respiratory rates position as possible. and the airway. absence of cyanosis. understand others and making breathing between 12 to 20 self-understand, with the during sleep, breath per 3.Hook the resident -To maintain airflow Goal partially meets: history of obstructive sleep pallor, shallow minutes, oxygen continuous positive airway during sleep. apnea and using CPAP. She is breathing and saturation within pressure (CPAP) machines After 24 hours of on full code and the degree of changes the target range, or other devices as evaluation, skin intervention is C2. respiratory and absence of prescribed by the doctor. pallor still visible to depth. pallor and Resident. History of Surgery: cyanosis. 4.Elivate the bed slightly prior to sleep. -Head elevation can prevent airway Current Medical History: obstruction and improve the expansion of the HTN, Arthritis, Renal failure, lungs, enabling the kidney stones, L leg DVT, L4-L5 patient to breathe more spinal stenosis, obstructive effectively even when sleep apnea, morbid obesity, sleep. multiple large abdominal hernia, GERD, Peripheral neuropathy, Diverticulosis, Hyperlipidemia, gouty, Hx of UTI. 2.After 1 week of intervention the 1.Assess respiratory muscle -Expiratory muscle work Goal meet: Subjective: resident will system in older adult with harder with the use of verbalize the the understanding that accessory muscle. After one week of Patient stated, “I stop ability to breath inspiratory muscle nursing intervention breathing 25 times during the comfortably. weakens, resulting in a the resident stated: night.” slight barrel chest. Monitor “my breathing is respiratory rate, depth, and doing okay, I can Objective: ease of respiration. breathe comfortably”. - Left leg deep thrombosis 2.Encourage resident to sit -To promote breathing Goal partially meets: -Protruding left abdomen up upright or stand as and expansion of the -Swollen leg both tolerated and avoid lying lungs. Resident verbalized: -Yawning down for prolonged period - “I understand the -Weakness during the day during the day. importance of -Pallor exercise, but I cannot -Wearing of glass to see in 3.Inspiratory muscle stand up so long my adequate light. training likely improves legs hurt me.” breathlessness during Physical Examination: exercise and/or with BP- 119/90 activities of daily living in PR-94bpm the client with morbid RR-18bpm obesity and history of sleep 02 sat: 96% room air. apnea. Temp: 36.5-degree Celsius Height: 151 cm 4.Increased client activity -Walking at least 10-20 Weight: 107kg to walking at least two minutes a day is BMI: 33 severe overweight. time a day as tolerated recommended for those unable to be in a structured program (GOLD, 2017)
After 8 hrs of Goal meet:
Mobility: Impaired gas nursing care the 1.Assess the patient vital -To create a baseline set Limited mobility due to exchange resident will signs, especially the of observation for the After 8 hours of morbid obesity and multiple related to demonstrate respiratory rate and depth patient, and to monitor nursing intervention abdominal hernia. She is using altered oxygen adequate during sleep. any changes in the vital the resident oxygen 4ww. supply oxygenation as signs as the patient saturation is 96% -unsteady gait secondary to evidence by an receives medical and HR is 94bpm. sleep apnea as oxygenation treatment Transfer: evidence by saturation and Two-person assist using apnea, morbid heart rate within 2.Monitor the color of skin -Peripheral cyanosis ceiling lift, she able to hold obesity and normal level. and mucous membrane. (bluish discoloration of properly and has a good grip. heart rate Check for any changes in the skin, earlobes, or nail below normal consciousness or presence beds) maybe evident with Nutritional Status: Moderate during sleep. of irritability and hypoxia. Central cyanosis in diabetic diet, regular restlessness. involving the mucosa may texture. indicate further reduction of oxygen levels. Changes Bed Mobility: Independent, in the level of she can turn position by consciousness may herself. indicate the state of hypoxia or impaired Dressing: Total Dependence oxygenation of the brain.
Bathing: Total dependence,
schedule of shower every 3.Monitor ABG levels. -To consistently check for Monday morning. respiratory function by monitoring the changes Bladder control: continent in pO2 and pCO2.
Allergies: Ramipril with cough,
Aspirin cause gastrointestinal upset. 4. Reposition the patient by elevating the head of the -To improve the delivery bed and encouraging her to of oxygen in the airways sleep in a side-lying and to reduce shortness position. Encourage pursed of breath and risk for lip breathing exercise airway collapse. Lab result: during waking hours.
Short term goal
2.After 8hrs of 1.If patient is obese Goal meet:
nursing consider positioning in -Trendelenburg position intervention the Trendelenburg position 45 at 45 degrees result in After 8 hours resident will degree for period as increase tidal volumes rendering nursing verbalize tolerated. and decreased care the goal was understanding of respiratory rates. meet as evidence by: using (CPAP) and 2.Regularly check the other therapeutic position of the resident so -Slumped positioning Resident intervention that or she does not slump causes the abdomen to demonstrated how down in bed. compress the diaphragm to use the CPAP and limits full lung machine. expansion.
3 Hook the resident
continuous positive airway -To maintain airflow pressure (CPAP) machines during sleep. or other devices as prescribed by the doctor.
4. Consider the patients
nutritional status -Certain condition affect lung expansion. Obesity may restrict downward movement of the diaphragm, increasing the risk for atelectasis, hypoventilation, and respiratory infection. Labored breathing is present in severe obesity as a result of excessive weight of the chest wall.