Myrna Cruz, a 68 year old female presents to the emergency department with shortness

of breath and dyspnea with exertion. She reports swelling of the feet and ankles and a
weight gain of 10lb over the past week but denies pain. The client has a history of
myocardial infarction 3 years previously, a 30-pack year smoking history, and obesity.
She has no known allergies. Her current medications are: Metoprolol (Toprol-XL) 50 mg
PO and daily Aspirin 81 mg PO. Upon assessment, the nurse noted that Myrna’s jugular
vein is distended, her respirations are shallow and labored even at rest. Other assessment
findings include; presence of moist crackles in anterior and posterior bilateral lower
lobes, moist nonproductive cough, 3 + pedal and ankle edema bilaterally, and skin of
lower extremities is pale and taut bilaterally. Vital Signs: weight of 256 lb, BP 188/96
mm Hg, HR: 126 bpm, respiratory rate: 24 per minute.
1. Identify three priority Nursing diagnoses.
● Ineffective breathing Pattern related to shortness of breath and dyspnea as
evidenced by shallow and labored respiration
● Ineffective Tissue perfusion related to edema as evidenced by swelling feet
and ankles
● Ineffective Airway Clearance related to retained mucous secretion as
evidenced by nonproductive cough

2. Make a Nursing Care Plan based on your identified Nursing diagnoses – Choose
only 1 priority nursing diagnosis
 NURSING CARE PLAN
Identified Problem: Shortness of breath and dyspnea

Nursing Diagnosis: Ineffective

breathing Pattern related to shortness of breath and dyspnea
as evidenced by shallow and labored respiration

CUES OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective: Short term 1. Place patient with A sitting position permits Short term:
objectives: proper body alignment maximum lung excursion
none for maximum breathing and chest expansion.
After 8 hrs of nsg pattern.
interventions,
patient maintains 2. Provide respiratory
an effective medications and to relax airway smooth
breathing pattern, oxygen, per doctor’s muscles and cause
Objective: as evidenced by orders. bronchodilation to open
relaxed breathing air passages.
- Shortness of at normal rate and Long term:
breath depth and
absence of 3. Maintain a clear
- dyspnea dyspnea. airway by encouraging This facilitates adequate
patient to mobilize own clearance of secretions.
- shallow and Long term secretions with
labored objectives: successful coughing.
breathing
After 3 days of nsg 4. Encourage frequent Extra activity can worsen
interventions, rest periods and teach shortness of breath.
patient will patient to pace activity Ensure the patient rests
demonstrate between strenuous
increased air activities.
exchange.
5. Consult dietitian for it may cause malnutrition
dietary modifications. which can affect breathing
pattern. Good nutrition
can strengthen the
functionality of respiratory
muscles.

6. Encourage small This prevents crowding of

frequent meals.. the diaphragm.

7. Educate patient or These allow sufficient

significant other proper
 breathing, coughing, mobilization of secretions.
and splinting methods

8. .Educate patient
about medications: This information promotes
indications, dosage, safe and effective
frequency, and possible medication administration.
side effects. Incorporate
review of metered-dose
inhaler and nebulizer
treatments, as needed.