A Nursing Care Plan on

INEFFECTIVE BREATHING PATTERN

In Partial Fulfillment of the

Requirements in NCM 216 - RLE

GI/METABOLISM AND ENDOCRINE ROTATION

Submitted to:

Mrs. Soraida Basallaje, RN, MN

Clinical Instructor

Submitted by:

Quisha Anne Acuña St.N

BSN 3H Group 3 Subgroup 1

February 1, 2024
CLUSTERING OF CUES

GORDON’S HEALTH PATTERN CUES PRIORITY

HEALTH PERCEPTION AND ● No medications were taken. LOW

MANAGEMENT PATTERN ● At the age 18, he started to smoke 5-6 cigarettes daily and drank 15-20
units of alcohol per week.

NUTRITIONAL AND METABOLIC ● 6-month history of reduced appetite and weight loss from 78 to 71kg. HIGH
PATTERN ● Weight loss evident in limbs.
● 3-month history of intermittent nausea in the morning.
● IVF: PNSS @LMV running at 100cc/hr.
● The patient has plethoric features.
● Swelling and pitting edema of ankles in the past month.
● Nine spider nevi on the upper trunk.
● Liver function tests indicate hepatic failure.
● Ultrasound of the abdomen showed a slight reduction in liver size and an
increase in splenic length of 2-3 cm.
● Clubbing of fingers noted.
● Distended abdomen.
● No palpable masses but there is shifting dullness and fluid thrill.
● Laboratory results:
○ Haemoglobin 12.6 g/dL (13.3–17.7 g/dL)
 ○ Mean corpuscular volume (MCV) 107 fL (80–99 fL)
○ Sodium 131 mmol/L (135–145 mmol/L)
○ Urea 2.2 mmol/L (2.5–6.7 mmol/L)
○ Total protein 48 g/L (60–80 g/L)
○ Albumin 26 g/L (35–50 g/L)
○ Bilirubin 25 mmol/L (3–17 mmol/L)
○ Alanine transaminase 276 IU/L (5–35 IU/L)
○ Gamma-glutamyl transaminase 873 IU/L (11–51 IU/L)
○ Alkaline phosphatase 351 IU/L (30–300 IU/L)
● ABG result: Metabolic acidosis

ELIMINATION PATTERN ● 3-month history of intermittent nausea in the morning and accompanied MEDIUM
with vomiting on several occasions.
● A retention catheter is placed with a urine output of 10-15 cc/hr.

ACTIVITY AND EXERCISE PATTERN ● Portal hypertension has developed. HIGH

● Vital signs:
○ PR: 92 BPM
○ BP: 156/94 mmHg
○ RR: 34 cpm
○ CR: 94 bpm
○ O2sat: 88%
 NURSING CARE PLAN

Name of Patient: JR Age/Sex: 45/Male Ward: St. Luke Room & Bed#:

Chief Complaint: intermittent nausea and vomiting in the morning, reduced appetite and weight Attending Physician: Dr. Kie

Diagnosis:

DATE/ CUES NEED NURSING PATIENT NURSING IMPLEME EVALUATION

TIME DIAGNOSIS OUTCOME INTERVENTIONS N
TATION

F Objective: A Ineffective After 1 hour of ● Position the patient 1

E - Portal breathing pattern nursing appropriately with the
C
B hypertensio related to intervention, head elevated
T
R n increased the patient will (High-Fowlers) to facilitate
U - Distended I abdominal be able to breathing.
A abdomen pressure as exhibit an Rationale:
V
R - shifting evidenced by effective Positioning the patient
I
Y dullness distended respiratory appropriately can help open up
and fluid T abdomen, pattern as the airways and reduce the
1, thrill respiratory rate of indicated by a work of breathing. Elevating
Y
- RR: 34 cpm 34 cpm and O2 respiratory rate the head of the bed can
/
2024 - O2 sat: saturation of 88% within 16-20 optimize lung expansion and
 88% E cycles per ease pressure on the
(7-3 Domain 4. minute and an diaphragm.
X
shift) Activity/rest O2 saturation
E
level greater ● Encourage proper
@ R Class 4: than or equal to breathing techniques such
8:00 AM Cardiovascular/ 90%. as slow deep breathing 2
C
pulmonary and pursed-lip breathing.
I
responses Rationale:
S Appropriate breathing
Diagnosis code: techniques increase air
E
00032 exchange. Pursed-lip
breathing allows for controlled
P Rationale: ventilation.
Ineffective
A
breathing pattern ● Administer oxygen as
T
can occur in ordered by the physician.
T patients with liver Rationale: Administer 3
disease. Ascites, supplemental oxygen as
E
a medical prescribed to promote
R
condition oxygenation and relieve
N characterized by respiratory
an abnormal
accumulation of ● Monitor vital signs,
fluid in the especially respiratory rate
abdominal cavity, and oxygen saturation 4
often occurs as a level frequently.
consequence of Rationale:
liver damage. The Monitoring vital signs enables
liver's impaired prompt recognition of
functionality deteriorating respiratory status
results in the and facilitates appropriate
buildup of management of ineffective
pressure within breathing patterns.
the veins
supplying the liver, ● Monitor the patient’s fluid
leading to a intake and output.
phenomenon Rationale: implement 5
known as portal measures to reduce abdominal
hypertension. This distension such as restriction
increased of fluid intake or administration
pressure forces of diuretics under medical
fluid to supervision.
accumulate in the
abdominal cavity, ● Encourage ambulation
causing distension and mobility if not
and discomfort. contraindicated. 6
However, the Rationale: Ambulation
detrimental effects promotes circulation and
of ascites extend respiratory function. Assist the
beyond mere patient with repositioning to
physical prevent pooling of fluids in the
discomfort, as abdomen.
individuals
suffering from this ● Provide patient education
condition and encourage adherence
commonly to the treatment. 7
experience Rationale: Provide education
shortness of on factors contributing to
breath. ineffective breathing patterns
and strategies to optimize
References: respiratory function.
Dugdale, D. C., & Adherence to the treatment
Conaway, B. (2022, can lead to better health
July 30). Ascites - outcomes.
Symptoms and
Causes. Penn
● Monitor for complications
Medicine. Retrieved or signs of respiratory
February 1, 2024, distress.
from Rationale: Signs of respiratory 8
https://www.pennme
distress such as increased
dicine.org/for-patien
work of breathing, cyanosis or
ts-and-visitors/patie
altered mental status should
nt-information/condi
be watched out.
tions-treated-a-to-z/
ascites
● Collaborate with
respiratory therapists and
implement a
comprehensive care plan. 9
Rationale: Collaborating with
other members of the
healthcare team can help
ensure that the patient
receives optimal care and that
interventions are coordinated
and consistent with the
patient's needs. A
comprehensive care plan can
improve outcomes and reduce
complications related to
ineffective breathing patterns.

● Provide emotional support.

Rationale: Offer emotional
support and reassurance to
the patient and family
members, addressing
concerns and promoting 10
coping strategies during
periods of respiratory difficulty.
References:

Belleza, M. (2023, July 21). Hepatic Cirrhosis Nursing Care Management and Study Guide. Nurseslabs. Retrieved February 1, 2024, from
https://nurseslabs.com/hepatic-cirrhosis/
NANDA (2021). Ineffective Breathing Pattern. NANDA International, Inc. Nursing Diagnoses 2021-2023 Twelfth Edition p. 295. ISBN
978-1-68420-454-0
Wagner, M. (2023, May 24). Ascites: Nursing Diagnoses, Care Plans, Assessment & Interventions. NurseTogether. Retrieved February 1, 2024, from
https://www.nursetogether.com/ascites-nursing-diagnosis-care-plan/