Nursing breath sounds, oxygen saturation, level of

Nursing Diagnoses Goal Interventions Rationales Evaluation
Ineffective breathing pattern related to musculoskeletal impairment (rib fracture) (Nanda, 2016, p.98) as evidenced by dyspnea, abnormal breathing pattern, presence of adventitious breath sounds (wheezes), cyanosis, tachycardia. The patient will have a patent airway and effective breathing pattern as evidenced by eupnea, clear breath sounds without wheezes, SpO2 98-100% (as per baseline data) and normal skin color within next 4 hours. (1) Assess the child for any pain/ discomfort, vital signs, cardiac rhythm, breath sounds, oxygen saturation, level of consciousness and other neurological changes (such as muscle weakness, seizures etc.).
Because all vitals including pain are impacted by changes in oxygenation, and a decreased level of consciousness and severe pain can be responsible factors of impaired oxygenation and respiratory distress (nanda. 2016, p.100, 359-360).
Goal has been met fully. After 4 hours of nursing interventions, C.K has clear airway and normal breathing pattern as evidenced by absence of wheezes, no signs of respiratory distress, SpO2 was 100% (normal as per patient’s baseline data), her lips, soles and mucous membranes were moist and pink,
normal skin turgor (