QLexNursing

Cardiopulmonary Actions

Encourage deep-breathing exercises.

🔹 Deep-breathing exercises help improve alveolar expansion, which increases oxygenation and supports gas exchange in a client with shallow respirations.

🔹 The nurse’s notes indicate that the client’s oxygen saturation improved after deep breathing, showing this intervention is already effective and should be continued.

🔹 Deep breathing also helps prevent atelectasis and postoperative or illness-related complications like pneumonia, especially in clients who may not be fully mobile.

🔹 Because the client has acute abdominal pain and hypovolemia, maintaining adequate oxygen delivery to tissues is essential to support overall perfusion.

🔹 This action directly aligns with the provider’s order for incentive spirometer education and use, reinforcing pulmonary hygiene and cardiopulmonary stability.

Check for pain.

🔹 The client reports abdominal pain rated 3/10, so ongoing pain assessment is a critical nursing responsibility.

🔹 Uncontrolled pain can cause tachycardia, shallow breathing, and anxiety, which can negatively affect the cardiopulmonary status and overall stability.

🔹 Regular pain checks allow the nurse to determine when PRN morphine sulfate should be administered as prescribed, supporting both comfort and physiologic stability.

🔹 Assessing pain also helps detect worsening abdominal conditions (e.g., perforation, obstruction, peritonitis) if the pain intensity, location, or quality changes.

🔹 Documentation and reassessment after interventions are part of evidence-based pain management, ensuring the client receives safe and effective care.

Inform client to achieve two to four breaths per session when using incentive spirometer.

🔹 Standard teaching for an incentive spirometer is usually about 10 slow, deep breaths every hour while awake, not just two to four breaths per session.

🔹 Only encouraging two to four breaths would provide insufficient lung expansion, limiting the effectiveness of the device in preventing atelectasis.

🔹 In this client, who already has shallow respirations and needed deep-breathing exercises to improve saturation, inadequate IS use would not meet cardiopulmonary needs.

🔹 Teaching the wrong frequency or number of breaths can lead to poor adherence and ineffective pulmonary hygiene, increasing risk for respiratory complications.

🔹 The nurse must give accurate, evidence-based instructions for IS use to ensure the client receives the full benefit of the prescribed intervention.

Gastrointestinal Actions

Promote intake of oral fluids.

🔹 The client has had nausea, vomiting for 2 days, and five loose stools, placing them at high risk for fluid volume deficit and electrolyte imbalance.

🔹 The provider has ordered maintenance IV fluids plus to advance diet as tolerated, so gentle encouragement of oral fluids (as tolerated) supports rehydration alongside IV therapy.

🔹 Adequate hydration helps maintain circulating volume, supports renal perfusion, and can help prevent complications of hypovolemia such as decreased blood pressure and tachycardia.

🔹 Promoting oral fluids also helps replace gastrointestinal losses, especially from diarrhea, which can rapidly deplete both fluid and electrolytes.

🔹 The nurse should encourage small, frequent sips of appropriate fluids, monitoring for intolerance (e.g., increased nausea) while strictly recording intake and output (I&O) as prescribed.

Apply barrier ointment after bowel movements.

🔹 The client reports five loose stools since yesterday, which increases risk of perianal skin breakdown due to moisture, acidity, and friction.

🔹 Applying a barrier ointment (zinc oxide or similar) after each bowel movement helps protect the skin by creating a moisture barrier against stool.

🔹 Protecting the skin is an essential part of GI and integumentary care, especially when diarrhea is present, to prevent dermatitis, pain, and infection.

🔹 This intervention is simple, cost-effective, and highly preventive, supporting client comfort and promoting skin integrity during the acute illness.

🔹 Combined with prompt cleansing after each stool and good hygiene, barrier ointment supports holistic care for a client experiencing frequent loose stools.

Encourage the client to increase fiber in their diet.

🔹 The client is experiencing acute abdominal pain, nausea, vomiting, and loose stools, which are not appropriate conditions for encouraging increased dietary fiber.

🔹 High-fiber intake is more appropriate in conditions like constipation or chronic bowel regulation, not when the client already has diarrhea and GI upset.

🔹 Increasing fiber now could worsen cramping, bloating, and stool frequency, further aggravating fluid and electrolyte loss.

🔹 The provider has ordered to advance the diet as tolerated, meaning the priority should be tolerable, gentle foods and fluids, not fiber-heavy meals.

🔹 Once the acute GI symptoms resolve, the nurse and provider may reassess long-term dietary needs, but fiber increase is not a priority in this acute hypovolemic, diarrheal state.