Question

Mrs. Tang, a 55 year old Caucasian female have just been diagnosed with Obstructive Sleep Apnea. She has a history of Hypertension and Diverticulitis.
Her BMI is 36.
Allergy: Aspirin
Meds-Lisinopril 10mg daily; Colace 100mg every other day.
VS: 179/98, 98.7, 82, 18. 92% on Room Air.

Design a care plan for this patient with at least 1 Nursing dx, 4 subjective & 4 objective data, 1 goal, 6 interventions, and evaluation.

Answer 1

Nursing Diagnosis : Ineffective Breathing pattern related to impaired regulation evidenced by Apnea during sleep ,change in respiratory depth as well as pallor, cyanosis.

Subjective Data : Verbalize breathing difficulty , Patient verbalize feeling cold

Objective Data : use of accessory muscle during breathing , pallor, cynosis , poor capillary refilling etc

Goal : Patient will maintain respiratory status to baseline parameters for pattern rate, depth, and ease.

Nursing Interventions	Rationale
Assess the nail bed, skin, mucous membranes for pallor or cyanosis.	Reveals presence of hypoxemia causing cyanosis from an uneven distribution of gases and blood in the lungs, and alveolar hypoventilation caused by airway obstruction and absence of chest wall movement.
Place the client on an apnea monitor and pulse oximeter.	Identify changes in the chest movement, heart rate, and oxygen saturation caused by apnea.
Position the patient in fowlers postion	If the neck bends too far forward or backward, blockage of breathing can happen.
Avoid prolonged suctioning; Discourage taking rectal temperatures and tube feedings.	Vagal stimulation may cause bradycardia, triggering apneic episodes.
Monitor ABG levels and oxygen saturation.	Monitors hypoxia and respiratory function for pO2 and pCO2 changes resulting from an abnormal ventilatory drive.
Administer continuous nasal airflow or CPAP via a nasal mask, or a face mask.	Continuous positive airway pressure (CPAP) is administered for apnea thought to be related to collapse of the airway.
Administer methylxanthines as indicated.	A drug used to stimulate spontaneous respiration