Nursing Care - Respiratory Rate

Running Head: EVIDENCE-BASED PLAN FOR NURSING CARE
EVIDENCE-BASED PLAN FOR NURSING CARE
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EVIDENCE-BASED PLAN FOR NURSING CARE
Priority nursing assessments
According to the case scenario, there is a sudden deterioration in the respiratory
functioning of the patient manifested through a breathing difficulty. The priority assessments
are:
Respiratory Rate (RR)
Any alteration in the RR is the first indication of respiratory distress when a COPD
patient exhibits sudden breathing difficulty. RR is measured by counting the number of
breaths for a full minute. If RR goes above 20 breaths/minute, shortness of breath is indicated
(Al Rajeh & Hurst, 2016, p. 108).
Pulse oximetry
Low oxygen saturation (Sp02) in the blood is evaluated by pulse oximetry. When the
oxygen saturation level is found to be <90%, a low oxygen level in the blood is indicated,
which correlates the signs of shortness of breath (Garcia-Gutierrez et al., 2015, pp. 613-620).
Factors contributing to dyspnoea
Two vital factors which could have led to this situation are:
 Exacerbation of COPD by breathing difficulties may have developed as a potential
side effect of the daily application of Exelon 10 Transdermal patch to decrease the
symptoms of Alzheimer’s disease (Accessdata.fda.gov, 2020). Acute dystonic
reactions may be caused by the administration of rivastigmine cholinergic drugs
(Exelon patch). The underlying mechanism involves a drug-induced modification in
the dopaminergic–cholinergic stability of the nigrostriatal path, leading to spasmodic
motor disturbances (Dhikav & Anand, 2013, pp. 1385-1386).
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Name, Student number, Unit code, 797

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EVIDENCE-BASED PLAN FOR NURSING CARE
 Another underlying cause could be hypoxemia, common in patients with long term
CPD (Ko et al., 2016, pp. 1152-1165). In this case, the low oxygen levels in the blood
could have resulted due to an increased oxygen demand from excessive work to
breathe as well as by insufficient cardiac reserve for the higher cardiac output, thereby
contributing to the dyspnoea experienced during an acute onset.
Care priorities
Using the Specific, Measurable, Achievable, Relevant, and Timely (SMART) goal
framework, the priorities of care are:
 To provide the patient with relief from her complications of acute dyspnoea
 To reduce the risk of recurring episodes of breathlessness by a significant reduction in
her elevated respiratory rate and increase the blood oxygen levels.
 The identified goal can be successfully administered via frequent monitoring of the
vital signs and ensuring the administration of appropriate medications on time.
 At the end of every session with the patient, detailed charting and documenting every
point regarding the nurse-patient interaction while they are still fresh on the mind is
essential to detect any risk factors early. It also helps in streamlining the work for the
nurse in the next shift.
 There will be no exacerbation of COPD relapse within a week. The focus will be on
providing the patient with symptomatic relief by the end of one week.
Nursing interventions
Diagnostic interventions should emphasize on chest roentgenography and arterial
blood sampling to achieve specif results. Literature suggests evidence of routine chest X-rays
being particularly useful in the initial detection of acute exacerbation of COPD. Similarly,
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Name, Student number, Unit code, 797