Shortness of breath nursing diagnosis

The American Thoracic Society defines dyspnea as a subjective experience of breathing discomfort that comprises qualitative distinct sensations that vary in intensity. 1 If symptoms persist for ...

Introduction. Shortness of breath is a very common cause of Emergency Department visits. In the United States, pneumonia, COPD exacerbation, heart failure exacerbation and dysrhythmias round out the top five reasons for hospital admission in patients 45 and older, after chest pain. All of those conditions, and many others, can cause shortness ...Case Presentation. History of Present Illness: A 33-year-old white female presents after admission to the general medical/surgical hospital ward with a chief complaint of shortness of breath on exertion. She reports that she was seen for similar symptoms previously at her primary care physician’s office six months ago. Ineffective Airway Clearance Explanation: Because wheezing, shortness of breath, and coughing are signs of a constricted airway, the nursing diagnosis of Ineffective Airway Clearance is the appropriate diagnosis. Bronchial pneumonia and Asthma Attack are both medical diagnoses. Introduction. Dyspnea is a broad term indicating a variety of unpleasant sensations related to breathing, including air hunger (the sensation which can be elicited by prolonging a breath-hold), sense of work/effort, or of chest tightness [1, 2].Dyspnea can vary in intensity and quality depending on the underlying pathophysiological mechanism, …Written by. Maegan Wagner, BSN, RN, CCM. Acute respiratory failure occurs when there is inadequate oxygenation, ventilation (carbon dioxide elimination), or both. It can be classified as hypoxemic or hypercapnic. Hypoxemic respiratory failure describes inadequate oxygen exchange between the pulmonary capillaries and the alveoli.1. Monitor the vital signs. Blood pressure and pulse rate first increase with the severity of hypoxemia/hypercapnia but later fall as the impairment to gas exchange worsens. It can reveal respiratory rate and oxygen saturation alterations as gas exchange continuously impairs. 2.Diagnosis of Shortness of Breath Doctors and nurses will assess the airway, breathing, and circulation (ABCs) to see if emergency treatment is required. If this isn’t the case, a series of tests will be performed to figure out what’s causing the dyspnea.

In the U.S., up to 4 million emergency room visits every year involve shortness of breath. One study found that 13% of all emergency medical service (EMS) calls are for breathing problems.. If you ...Atrial fibrillation is the most common type of heart arrhythmia. It is due to abnormal electrical activity within the atria of the heart causing them to fibrillate. Is characterized as a tachyarrhythmia, which means that the heart rate is often fast. This arrhythmia may be paroxysmal (less than 7 days) or persistent (more than 7 days). Due …When symptoms are present, they often develop suddenly. 1 The most common symptoms associated with a pneumothorax are shortness of breath and chest pain. 1,4 Patients will often describe the chest pain as severe, sharp, and stabbing. 1 They may also report chest pain that radiates to the shoulder and arm. 1 If the patient has an open wound, the nurse …Feb 19, 2023 · Dyspnea, commonly referred to as shortness of breath, is the subjective sensation of uncomfortable breathing comprised of various sensations of varying intensity. It is a common symptom impacting millions of people and maybe the primary manifestation respiratory, cardiac, neuromuscular, psychogenic, systemic illness, or a combination of these. Dyspnea can be either acute or chronic with acute ... Subjectives. This condition of impaired spontaneous ventilation can present with many different subject symptoms. These typically include a feeling of shortness of breath, dizziness, fatigue, confusion and anxiety. Other related physical symptoms may consist of chest pain, labored breathing, tachypnea (rapid breathing) and cyanosis (blue ... A client reporting shortness of breath is admitted with a diagnosis of cirrhosis. A nursing assessment reveals an enlarged abdomen with striae, an umbilical hernia, and 4+ pitting edema of the feet and legs. What is the most important data for the nurse to monitor? A. Hemoglobin B. Albumin C. Bilirubin D. Temperature

Ineffective Airway Clearance Nursing Interventions. Administer supplemental oxygen and bronchodilators as prescribed. Encourage deep breathing and coughing exercises. Position the client upright to promote lung expansion. Assist the client with positioning to promote effective breathing. Monitor the client’s oxygen saturation levels and lung ...Introduction. Shortness of breath is a very common cause of Emergency Department visits. In the United States, pneumonia, COPD exacerbation, heart failure exacerbation and dysrhythmias round out the top five reasons for hospital admission in patients 45 and older, after chest pain. All of those conditions, and many others, can cause shortness ...Jun 11, 2023 · RN, BSN, PHN. Ineffective breathing pattern refers to an abnormal or inefficient way of breathing that hampers the exchange of oxygen and carbon dioxide in the body. The patient may experience difficulties in taking in an adequate amount of air or exhaling fully. This can result in a decreased oxygen supply to the body’s tissues and an ... Through these nursing diagnoses, an effective nursing care plan can be formulated to provide optimal and individualized nursing care. However, here are some examples to consider: Activity Intolerance related to chronic respiratory conditions (e.g., COPD) as evidenced by shortness of breath during minimal physical exertion, use of accessory ...Nursing Interventions. Nursing interventions for the patient with MERS-CoV include the following: Monitor vital signs. Monitor the patient’s temperature; the infection usually begins with a high temperature; monitor the respiratory rate of the patient as shortness of breath is another common symptom. Educate the patient and folks.Dyspnea (shortness of breath) is the sensation of having trouble breathing. It is a symptom of many lung and heart conditions and can be acute or chronic.

Meaning of itchy nose.

Shortness of breath (dyspnoea) is a common emergency presentation and is a symptom of many different medical conditions, both acute and chronic. Most cases of acute shortness of breath are due to lung and breathing disorders, cardiovascular disease, or chest trauma. It is a condition which some patients may experience many … Sufficient oxygenation is vital to maintain life. When prioritizing nursing interventions, we often refer to using the “ABCs,” an acronym used to signify the importance of maintaining a patient’s airway, breathing, and circulation. Several body systems work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately ... Therapeutic interventions and nursing actions for patients with anaphylactic shock may include: 1. Promoting Effecting Breathing Patterns. Ineffective breathing pattern can occur in patients with anaphylactic shock due to bronchospasm, bronchoconstriction, laryngeal edema, and facial angioedema.Subjectives. This condition of impaired spontaneous ventilation can present with many different subject symptoms. These typically include a feeling of shortness of breath, dizziness, fatigue, confusion and anxiety. Other related physical symptoms may consist of chest pain, labored breathing, tachypnea (rapid breathing) and cyanosis (blue ...9 Deep Vein Thrombosis Nursing Care Plans. Deep vein thrombosis (DVT) is a common and potentially life-threatening condition that requires prompt medical attention. As a nurse, understanding the nursing care plans and nursing diagnosis for DVT is essential to providing the best care for clients. This guide provides a comprehensive overview of ...

Jun 11, 2023 · Signs and Symptoms of Ineffective Airway Clearance. Abnormal breath sounds (e.g., crackles, wheezes, rhonchi) Abnormal respiration (rate, rhythm, and depth) Dyspnea or difficulty breathing. Excessive secretions. Hypoxia / cyanosis. Ineffective or absent cough. Orthopnea. Nursing Diagnosis: Impaired Gas Exchange related to pulmonary edema as evidenced by shortness of breath, SpO2 level of 85%, productive cough, and frothy phlegm Desired Outcome: The patient will maintain optimal gas exchange as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation above 96% …Among adults without reported COPD, the 3 respiratory symptoms indicating COPD (chronic cough, phlegm or mucus production, shortness of breath) were …-assigning clinical cues -defining characteristics -diagnostic reasoning -diagnostic labeling, A nurse is developing nursing diagnoses for a patient. Beginning with the first step, place in order the steps the nurse will use. 1. Observes the patient having dyspnea (shortness of breath) and a diagnosis of asthma. 2.While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. ... Impaired Physical Mobility related to obesity as evidenced by shortness of breath with activity, difficulty in standing or walking for prolonged periods, and reliance on others for assistance in mobility.Evaluate the respiratory rate, depth, pattern, and O2 saturation. Symptoms of pulmonary edema can progress rapidly. 3. Auscultate the breath sounds. Adventitious breath sounds like crackles, wheezing, or bubbling can be heard. Fine crackles heard on inspiration are specific to cardiogenic pulmonary edema. 5.Shortness of breath describes the sensation of not being able to breathe in a sufficient amount of air. Medically speaking, this state is known as dyspnea, and, in some cases, can ...Shortness of breath; Objective Data: The objective data for anxiety is observable and measurable data, or signs, obtained through observation, physical examination, and laboratory or diagnostic testing. ... The nursing diagnosis will be your clinical judgment about the patient’s health conditions or needs.

A significant portion of the AHA 2021 Scientific Sessions was focused on mentorship for early career individuals in research and medicine. Insights from the Interview with Nursing ...

1. Auscultate breath sounds and vital signs. Monitor blood pressure, heart rate, and sp02 closely. Auscultate lungs to assess for adventitious sounds such as rhonchi which could signal retained secretions. 2. Note the type of breathing pattern. Observe the rate, depth, and irregularity of the breathing pattern.Volunteer nursing is a great way to refresh your interest in medicine while helping others. Read about the training and benefits of volunteer nursing. Advertisement If you're invol...7 Nursing Diagnosis for Asthma. 1. Ineffective Airway Clearance. Ineffective airway clearance related to asthma results from the body's overproduction of antibodies and release of chemicals, which trigger tightening of the airways (bronchospasm), a major characteristic of asthma. This is often coupled with mucus buildup, which plugs the …Apr 30, 2024 · Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases. As with previous editions, the 2018 Global ... It will include three sample nursing care plans with NANDA nursing diagnoses, nursing assessment, expected outcome, and nursing interventions with rationales. Bronchial Asthma Case Scenario. A 17-year old female presents to the ED with complaints of severe shortness of breath and anxiety. The patient has a past medical …A nursing diagnosis is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or a vulnerability for that response, by an individual, family, group, or community.”. [6] Nursing diagnoses are customized to each patient and drive the development of the nursing care plan.The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. ... chronic obstructive lung disease who is receiving oxygen at 1.5 liters per minute via nasal cannula is complaining of shortness of breath. What action should the nurse take? Have the client ...Nursing Diagnosis. Impaired gas exchange related to decrease in functioning lung tissue as evidenced by hypoxemia and respiratory acidosis. Goal/Desired Outcome. Short-term goal: The patient will report an improvement in shortness of breath, be weaned down to 2L nasal cannula, and exhibit an improving acid-base balance by the …Sufficient oxygenation is vital to maintain life. When prioritizing nursing interventions, we often refer to using the “ABCs,” an acronym used to signify the importance of maintaining a patient’s airway, breathing, and circulation. Several body systems work collaboratively during the oxygenation process to take in oxygen from the air, carry it through the bloodstream, and adequately ...

Aa e175.

Paul le mat daughters.

The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic …The common symptoms of COPD include shortness of breath, coughing, wheezing, and chest tightness. COPD can also cause fatigue, weight loss, and difficulty sleeping. Diagnosis of COPD. ... To address these nursing diagnoses, nursing interventions such as providing education, administering medications, implementing fall …Apr 30, 2024 · Dyspnea or ineffective breathing pattern is a state of abnormal breathing rate, depth, rhythm, or pattern. It can be caused by various factors such as heart failure, hypoxia, airway obstruction, infection, anxiety, or pain. The nursing care plan and management guide for clients experiencing dyspnea involves assessing the underlying cause, promoting gas exchange, relieving anxiety and distress, and providing education. Clipboard Health, a company developing a platform to match healthcare workers with shifts at health facilities, has raised $80 million in venture capital. Clipboard Health, an app-...Shortness of breath/dyspnea; Respiratory depth changes; Alterations in ABGs; Expected outcomes: Patient will demonstrate an effective respiratory pattern as indicated by a respiratory rate within 12-20 breaths/min with normal depth and absence of cyanosis. Patient will express the relief of shortness of breath/dyspnea.Explore the best online bachelor's in nursing programs and discover which online prerequisites for nursing you need to start your educational journey. Updated April 19, 2023 thebes...When symptoms are present, they often develop suddenly. 1 The most common symptoms associated with a pneumothorax are shortness of breath and chest pain. 1,4 Patients will often describe the chest pain as severe, sharp, and stabbing. 1 They may also report chest pain that radiates to the shoulder and arm. 1 If the patient has an open wound, the ...Chapter 28: Caring for Clients with Heart Failure. When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating. orthopnea. dyspnea upon exertion. hyperpnea. paroxysmal nocturnal dyspnea. Click the card to flip 👆. Orthopnea. Click the card to flip 👆. Study with Quizlet and memorize flashcards containing terms like A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis?, When writing an actual nursing diagnosis, the nurse includes the etiology that contributes to the current situation. This would be identified as:, A client ... Shortness of Breath (Dyspnea) Nursing Diagnosis & Care Plan Dyspnea often called shortness of breath (SOB), is used to describe difficult or labored breathing often with an increased respiratory rate. Shortness of breath is not a disease but a symptom. Dyspnea can be acute or chronic depending on the causative factor.Dyspnea, or breathing discomfort, is a common symptom that afflicts millions of patients with pulmonary disease and may be the primary manifestation of lung disease, myocardial ischemia or dysfunction, anemia, neuromuscular disorders, obesity, or deconditioning. ….

Let’s go over the nine most common disorders and conditions linked to shortness of breath. Respiratory disorders: Asthma, COPD, pneumonia, COVID-19, pulmonary embolism, …In SCLC, clients usually experience shortness of breath; physical examination may reveal the use of the accessory muscles of respiration and nasal flaring (Tan & Karim, 2021). Observe changes in skin or mucous membrane color, pallor, cyanosis, and edema. ... Recommended nursing diagnosis and nursing care plan books and …NANDA Nursing Diagnosis Definition. Ineffective breathing pattern, according to NANDA (North American Nursing Diagnosis Association), is defined as a decreased oxygenation level and airway obstruction due to complications from certain medical conditions, such as chronic obstructive pulmonary disease (COPD), asthma, bronchitis, congestive heart ...Dyspnea is a symptom, not a discreet disease, and can be present in the absence of disease, or be the net result of multiple disease processes. It is an extremely common symptom. About 25% of patients seen by the physician in the ambulatory setting present with dyspnea. This number can be as high as 50% in the tertiary care setting. 1.Anemia is a condition where a patient has a below normal level of red blood cells. This can cause symptoms like fatigue, dizziness, weakness and shortness of breath.Nursing Diagnosis: Ineffective Breathing Pattern related to bacteria-caused pleurisy as evidenced by shortness of breath and cough Desired Outcome: The patient will achieve effective breathing pattern as evidenced by respiratory rates between 12 to 20 breaths per minutes, oxygen saturation of above 96%, and verbalizes ease of breathing.Abstract. This chapter addresses the fundamental nursing in managing breathlessness. Every nurse should possess the knowledge and skills to assess patients holistically, to select and implement evidence-based strategies, to manage breathlessness, and to review the effectiveness of these to inform any necessary changes in care.The following are the nursing priorities for patients with congestive heart failure: Improve myocardial contractility and perfusion. Enhance heart’s pumping function to ensure adequate blood flow to organs through medications, monitoring vital signs, and optimizing fluid balance. Manage fluid volume.A cough is one of the most common medical complaints accounting for as many as 30 million clinical visits per year. Up to 40% of these complaints result in referral to a pulmonologist. A cough is an innate primitive reflex and acts as part of the body’s immune system to protect against foreign materials. Coughing is associated with a wide …9 Deep Vein Thrombosis Nursing Care Plans. Deep vein thrombosis (DVT) is a common and potentially life-threatening condition that requires prompt medical attention. As a nurse, understanding the nursing care plans and nursing diagnosis for DVT is essential to providing the best care for clients. This guide provides a comprehensive overview of ... Shortness of breath nursing diagnosis, The following are common signs and symptoms of an ineffective breathing pattern. They are categorized into subjective and objective data based on patient reports …, The patient is a 60-year-old white female presenting to the emergency department with acute onset shortness of breath. Symptoms began approximately 2 days before and had progressively worsened with no associated, aggravating, or relieving factors noted. She had similar symptoms approximately 1 year ago with an acute, chronic …, Shortness of breath, also known as dyspnea, is defined as a subjective feeling of difficulty breathing or breathlessness. undefined#ref6">6 Shortness of breath may be caused by many different conditions, such as acute respiratory failure (ARF), chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), pulmonary …, Nursing Diagnosis: Activity intolerance related to myocardial imbalance between oxygen supply and demand secondary to M.I. as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion. Risk for Ineffective Tissue Perfusion, A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? A) Bronchial Pneumonia B) Ineffective Airway Clearance C) Acute Dyspnea D) Asthma Attack, Mar 11, 2023 · 2. Administer pain medications as indicated. The heart rate can be slowed by medications to treat pain in tachycardia. Morphine can lessen the workload on the heart, slowing breathing and heart rate. 3. Ask the patient to perform vagal maneuvers. Instruct the patient to cough or bear down as if having a bowel movement. , Background Dyspnea (breathing discomfort) is a common and distressing symptom. Routine assessment and documentation can improve management and relieve suffering. A major barrier to routine dyspnea documentation is the concern that it will have a deleterious effect on nursing workflow and that it will not be readily accepted by nurses. Nurses at our institution recently began to assess and ..., A COPD diagnosis means you may have one of these lung-damaging diseases or symptoms of both. COPD can progress gradually, making it harder to breathe over time. ... including similar symptoms like shortness of breath and blocked airflow. However, COPD is chronic and progressive. Asthma is often set off by allergens. COPD’s main cause is …, Introduction. Shortness of breath is a very common cause of Emergency Department visits. In the United States, pneumonia, COPD exacerbation, heart failure exacerbation and dysrhythmias round out the top five reasons for hospital admission in patients 45 and older, after chest pain. All of those conditions, and many others, can cause shortness ..., Aug 10, 2020 · Breathlessness (dyspnoea) can be an extremely distressing sensation, often characterised by rapid and difficult breathing. It is associated with a range of other acute and long-term conditions, and is a key symptom of Covid-19, the disease caused by the novel coronavirus identified in 2019 (SARS-CoV-2) that has resulted in a global pandemic. , 2. Medical Diagnosis Cough; Shortness of breath; Wheeze. 4. Pathophysiology. Asthma is a common chronic disorder of the airways that involves a complex interaction of airlow obstruction, bronchial hyperresponsiveness and an underlying inlammation Secondary Medical Diagnosis, Nursing Diagnosis. Decreased cardiac output related to blood flow obstruction as evidenced by fatigue, shortness of breath, and right heart strain. Goal/Desired Outcome. Short-term goal: The patient remains hemodynamically stable overnight with a reduction in chest pain and shortness of breath by the end of the shift., Types of interventions. We will include interventions targeting respiration to relieve breathlessness according to the following prespecified categories. Breathing training or breathing control exercises (e.g. diaphragmatic breathing, pursed lip breathing, body position exercises, respiratory muscle training)., Atrial fibrillation is the most common type of heart arrhythmia. It is due to abnormal electrical activity within the atria of the heart causing them to fibrillate. Is characterized as a tachyarrhythmia, which means that the heart rate is often fast. This arrhythmia may be paroxysmal (less than 7 days) or persistent (more than 7 days). Due to its rhythm irregularity, blood flow through the ..., Shortness of breath. R06.02 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2024 edition of ICD-10-CM R06.02 became effective on October 1, 2023. This is the American ICD-10-CM version of R06.02 - other international versions of ICD-10 R06.02 may differ., A 74 year old male presents to the ER with complaints of swelling in legs and feet, shortness of breath with any type of activity, non-radiating chest pain, increase cough, and the inability to sleep laying down at night. ... Nursing Diagnosis: Fluid volume overload related to decreased cardiac output as evidence by ejection fraction of 35% ..., Acid reflux. Anaphylaxis (a severe type of allergic reaction) Neurological diseases such as multiple sclerosis. Other lung diseases such as sarcoidosis and bronchiectasis. Lack of regular exercise. Before dismissing shortness of breath as being due to inactivity, talk to your healthcare professional., NANDA Nursing Diagnosis Definition. Ineffective breathing pattern, according to NANDA (North American Nursing Diagnosis Association), is defined as a decreased oxygenation level and airway obstruction due to complications from certain medical conditions, such as chronic obstructive pulmonary disease (COPD), asthma, bronchitis, congestive heart ... , Coughing. It can be acute (sudden dyspnea) or chronic (long-lasting dyspnea). Acute dyspnea starts within a few minutes or hours. It can happen with other symptoms like a fever, rash, or cough ..., The most common causes of acute shortness of breath include: Respiratory tract infections, such as bronchitis or pneumonia. These infections usually cause other symptoms, such as fever, cough, or coughing up sputum or mucus. (See "Patient education: Pneumonia in adults (Beyond the Basics)" .) A severe allergic reaction (anaphylaxis), …, The primary symptom to assess when a patient is experiencing decreased oxygenation is their level of dyspnea, the medical term for the subjective feeling of shortness of breath …, Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases. As with previous editions, the 2018 Global ..., Through these nursing diagnoses, an effective nursing care plan can be formulated to provide optimal and individualized nursing care. However, here are some examples to consider: Activity Intolerance related to chronic respiratory conditions (e.g., COPD) as evidenced by shortness of breath during minimal physical exertion, use of accessory ..., At a nursing home, skilled staff and health care providers offer around-the-clock care. Nursing homes can provide a number of different services: At a nursing home, skilled staff a..., Dyspnea Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and demand as evidenced by fatigue, overwhelming lack of energy, verbalization of tiredness, generalized weakness, and shortness of breath upon exertion., Dyspnea ( shortness of breath) upon exertion or lying down. Jugular vein distention (JVD) Fatigue and reduced ability to exercise. Peripheral edema (swelling of …, Use a current, evidence-based nursing care plan resource when creating a care plan for a patient. Table 8.3b NANDA-I Nursing Diagnoses Related to Decreased Oxygenation and Dyspnea. Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane., 1. Auscultate breath sounds and vital signs. Monitor blood pressure, heart rate, and sp02 closely. Auscultate lungs to assess for adventitious sounds such as rhonchi which could signal retained secretions. 2. Note the type of breathing pattern. Observe the rate, depth, and irregularity of the breathing pattern., Nursing Care Plan and Management. Nursing care management for chest pain involves prompt assessment, effective pain management, and close monitoring of vital signs to ensure timely intervention and promote patient well-being. In this section, we’ll dive into the nursing care management for patients with angina pectoris (chest pain)., Apr 30, 2024 · This may indicate ineffective airway clearance. Auscultation helps the nurse assess the flow of air through the bronchial tree and evaluate the presence of fluid or solid obstruction in the lung. There are different kinds of adventitious breath sounds, and may include the following: Decreased or absent breath sounds. , In the U.S., up to 4 million emergency room visits every year involve shortness of breath. One study found that 13% of all emergency medical service (EMS) calls are for breathing problems.. If you ..., Nursing Diagnosis. Decreased cardiac output related to blood flow obstruction as evidenced by fatigue, shortness of breath, and right heart strain. Goal/Desired Outcome. Short-term goal: The patient remains hemodynamically stable overnight with a reduction in chest pain and shortness of breath by the end of the shift., Apr 30, 2024 · This may indicate ineffective airway clearance. Auscultation helps the nurse assess the flow of air through the bronchial tree and evaluate the presence of fluid or solid obstruction in the lung. There are different kinds of adventitious breath sounds, and may include the following: Decreased or absent breath sounds.