c.C: Circulation: Check the pulse. If the victim
has no pulse, artificial circulation must be
started with breathing.
14.The nurse is responsible for collecting the baseline
data before the examination. Pain medication
should be administered before the test if
requested. During the procedure, the nurse should
observe the patient for reactions. The patient’s
color, pulse, and respiratory rates should be
observed and any deviation from the norm
reported to the physician immediately. After the
procedure, the nurse should observe the patient
for changes in respirations. A chest x-ray is usually
done to verify the absence of complications.- a.Help the patient assume a position that allows
free movement of the diaphragm and expansion
of the chest wall to promote ease of respiration.
b.Keep the patient’s secretions thin by asking the
patient to drink 2 to 3 quarts of clear fluids daily.
c. Provide humidified air.
d.Perform cupping on the patient’s lungs to
loosen pulmonary secretions.
e.Use vibration to help loosen respiratory
secretions.
f. Provide postural drainage.
g.Help patient maintain good nutrition.
APPLYING YOUR KNOWLEDGE
REFLECTIVE PRACTICE USING CRITICAL
THINKING SKILLS
Sample Answers
1.How might the nurse respond to Ms. McIntyre’s
request for a DNR order while taking into consider-
ation the wishes of her daughter?
The nurse could check Ms. McIntyre’s chart for
advance directives or a living will and if one is not
executed, the nurse could help Ms. McIntyre fill
one out. The nurse should consult with the daugh-
ter and inform her of her mother’s wishes for a DNR
order. A counselor could be called in to facilitate the
process. When planning patient care, the nurse
should take into consideration age-related changes
that may be increasing Ms. McIntyre’s symptoms
and may respond to appropriate treatment and
therapy.
2.What would be a successful outcome for this
patient?
By next visit, Ms. McIntyre vocalizes understanding
of, and signs, an advance directive to direct her
future care and protect her rights as a patient.
3.What intellectual, technical, interpersonal, and/or
ethical/legal competencies are most likely to bring
about the desired outcome?Intellectual: knowledge of developmental variables
affecting respiratory function
Technical: ability to use the equipment and protocols
necessary to diagnose and treat respiratory problems
Ethical/Legal: knowledge of patients’ and families’
rights related to refusal of care
4.What resources might be helpful for Ms. McIntyre?
Legal counseling, family counseling, advance direc-
tives and living wills
PATIENT CARE STUDY
1.Objective data are underlined; subjective data are in
boldface.
Toni is a 14-year-oldgirl who is in the adolescent
mental health unit following a suicide attempt. Her
chart reveals that on several occasions when her
mother was visiting, she began hyperventilating
(respiratory rate of 42 and increased depth).Gasp-
ing for breath on these occasions, she nevertheless
pushed away all who approached her to assist. Her
mother confided that she and her husband are in
the midst of a divorce and that it hasn’t been easy
for Toni at home: “I know she’s been having a
rough time at school, and I guess I’ve been too
caught up in my own troubles to be there for
her.”When you attempt to discuss this with Toni
and mention her mother’s concern, she begins
hyperventilating again.
2.Nursing Process Worksheet
Health Problem: Ineffective breathing patterns
Etiology: Anxiety
Signs and Symptoms: Periods of hyperventilation
(increased RR [42] and increased depth) associated
with stressful situations (visits by mother)
Expected Outcome: By her second week in the unit
(3/22/11), Toni will demonstrate an effective respi-
ratory rate and rhythm (not to exceed 24) during
her mother’s visits.
Nursing Interventions:
a.Use interview questions directed to Toni and her
mother to determine the nature of the problem,
its probable cause, and its effect on her lifestyle.
b.Demonstrate consciously controlled breathing
and encourage her to use it during periods of
anxiety or activity.
c. Maintain an emotionally “safe” environment.
The same nurses should always work with this
patient and maintain eye contact during conver-
sations with her.
d.If fear is the cause of her anxiety, encourage her to
express concerns. Reduce cause of fear, if feasible.
e.If there is a strong emotional component, discuss
with the patient the possibility of developing effec-
tive coping skills with professional counseling.Copyright © 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins. Study Guide for Fundamentals of Nursing:ANSWER KEY 405
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