What is a nursing diagnosis rationale?
A nursing rationale is a stated purpose for carrying out a nursing intervention. The nursing diagnosis is a statement of an actual observed risk or potential problem of the patient. “Body image, disturbed,” Ineffective coping” and “Nutrition imbalanced: less than body requirements” are examples of nursing diagnoses.
What type of nursing diagnosis is ineffective breathing pattern?
Diagnoses
| NANDA-I Nursing Diagnoses | Definition |
|---|---|
| Ineffective Breathing Pattern | Inspiration and/or expiration that does not provide adequate ventilation. |
| Ineffective Airway Clearance | Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. |
What is the goal for shortness of breath?
The aim when positioning a patient with dyspnoea is to maximise respiratory function while reducing physical effort, therefore the individual should be comfortable and well supported.
Why is ineffective airway clearance a priority?
It should be pointed out that ineffective airway clearance, as well as other respiratory diagnoses, are usually priority because they directly affect tissue oxygenation, requiring quick and resolutive interventions.
How do you write a nursing intervention for rationale?
What to Include. The rationale for an intervention is the medical, nursing, husbandry, physiological, or pathophysiological reason why the intervention is carried out. In academic contexts, give references for the rationale. List and number the rationale according to the corresponding problem and intervention.
What are the three types of nursing interventions?
Types of Nursing Interventions There are different types of interventions: independent, dependent and interdependent.
What interventions can be done for terminally ill patients experiencing ineffective breathing patterns?
Types of interventions
- Breathing training or breathing control exercises (e.g. diaphragmatic breathing, pursed lip breathing, body position exercises, respiratory muscle training).
- Cool air (e.g. use of a handheld fan).
- Chest wall vibration.
What causes ineffective airway?
An ineffective cough compromises airway clearance and prevents mucus from being expelled. Respiratory muscle fatigue, severe bronchospasm, or thick and tenacious secretions are possible causes of ineffective cough. Note presence of sputum; evaluate its quality, color, amount, odor, and consistency.
What does ineffective airway clearance mean?
Ineffective airway clearance occurs when an artificial airway is used because normal mucociliary transport mechanisms are bypassed and impaired. Nursing assessment and intervention are the keys to maintaining airway patency in the patient with an artificial airway in place.
Why is effective airway clearance important?
Effective airway clearance is a critical component of CF therapy. To maintain lung health, physical removal of airway secretions is needed to not only relieve airway obstruction but also to reduce infection and airway inflammation.
What is ineffective tissue perfusion related to?
ineffective Tissue Perfusion [specify] may be related to decreased arterial blood flow, possibly evidenced by BP changes, diminished pulses, edema, dyspnea, dysrhythmias, altered mental status, decreased renal function.
What is a rationale example?
A decision rationale describes the reasons for a decision. For example, a decision to reject a business plan may explain the risks or shortcomings of the plan. The business plan was rejected because the business model created value for customers by creating large risks for us.
Why is it important to have an effective breathing pattern?
Therefore, having a clear and effective breathing pattern is vital in inpatient care. Proper management for patients with an ineffective breathing pattern is aimed at sustaining or improving pulmonary ventilation and oxygenation, promote comfort and ease of breathing while improving the patient’s ability to participate in physical activities.
When do you need an ineffective breathing pattern care plan?
An ineffective breathing pattern care plan is needed when inspiration or expiration or both do not maintain optimum ventilation for an individual. It also refers to the state in which the depth, rate, timing, and rhythm of breathing becomes altered. When the breathing pattern is ineffective, the body tissues most like will not get adequate oxygen.
What happens when the breathing pattern is ineffective?
Having a clear and effective airway is number one in patient care. When the breathing pattern is ineffective, the body is most likely not getting enough oxygen to the cells. This can result in complications and slow recovery time.
How to determine effective breathing pattern for COPD patients?
Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths or cycles per minutes, oxygen saturation of above 96% (88 to 92% if COPD patient) and verbalizes ease of breathing. Assess the patient’s vital signs and characteristics of respirations at least every 4 hours.