The nurse is caring for a patient who is recovering from thoracotomy surgery. The patient's respirations are regular but very shallow. Which intervention is the highest priority for the nurse to include in the patient's care plan for the diagnosis:
Ineffective breathing pattern r/t fatigue and pain?
a.
Encourage the patient to use incentive spirometer after administration of pain medication.
b.
Ask the patient to describe prior pain experiences and effectiveness of methods used to manage pain.
c.
Help the patient to understand that comfort is a priority goal of nursing care in the postoperative period.
d.
Assist the patient to minimize the effects of pain on interpersonal relationships with family members.
ANS: A
The highest priority intervention for the ineffective breathing pattern diagnosis is to have the patient use the incentive spirometer after pain medication has been given. The spirometer will encourage the patient to take needed deep breaths, and pain medication will make it less painful for the patient to do so. The other interventions do not address breathing pattern.
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