1 Ineffective Breathing Pattern

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

Assessment Subjective: Dyspnea Objectives: The patient manifested the following:

Tachypnea Presence of crackles on both lung fields upon auscultation use of accessory muscles RR of 28

The patient may manifest the following:

Cyanosis Orthopnea Diaphoresis

Nursing Nursing InterExpected Planning Rationale Diagnosis ventions Outcome Ineffective Short Term: - Establish - To gain pt/ Short Term: Breathing rapport SOs trust and After 3 hours The patient Pattern RT cooperation of nursing - Monitor and shall have Decreased interventions record vital - To obtain demonstrated Lung the patient signs baseline data appropriate Volume will coping Capacity demonstrate - Assess breath - To note for behaviors and as appropriate sounds, methods to respiratory evidenced coping improve respiratory rate, abnormalities by behaviors and depth and that may indicate breathing tachypnea, methods to rhythm early respiratory pattern. presence of improve compromise and crackles on breathing Long term: - Elevate head hypoxia both lung pattern. of the pt. fields and - To promote The patient dyspnea Long term: - Provide lung expansion shall have applied relaxing After 1 to 2 environment techniques - To promote days of that improved adequate rest nursing periods to limit breathing - Administer interventions, supplemental fatigue pattern and be the patient free from oxygen as would be able ordered - To maximize signs and to apply oxygen available symptoms of techniques respiratory -Assisst client in for cellular that would distress AEB uptake the use of improve respiratory relaxation breathing rate within technique -To provide pattern and be normal range, relief of free from causative factors absence of - Administer signs and cyanosis, prescribed symptoms of medications as - For the effective respiratory ordered pharmacological breathing and distress. management of minimal use of accessory the patients -Maximize muscles

respiratory condition during effort with good breathing. posture and -To promote effective use if wellness accessory muscles. - to limit fatigue -Encourage adequate rest periods between activities

2 Impaired Gas Exchange

Impaired gas exchange is a state in which there is excess or deficit oxygenation and carbon dioxide elimination. The compensatory mechanism of lungs is to lose effectiveness of its defense mechanisms and allow organisms to penetrate the sterile lower respiratory tract where inflammation develops. Disruption of mechanical defenses and ciliary motility leads to colonization of lungs and subsequent infection. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. The release of endotoxins by the microbes can lodge in the brain, affecting the respiratory center in medulla resulting to altered oxygen supply.

Nursing Nursing InterExpected Planning Rationale Diagnosis ventions Outcome Subjective: Impaired Short term: - Establish rapport - To gain Short term: (none) Gas pt./SOs trust After 1 hour - Monitor and record The patient Exchange and cooperation of nursing vital signs shall have Objective: R/T interventions, verbalized - To obtain Alveolar understanding The patient Capillary the pt will - Monitor respiratory baseline data verbalize of the manifested Membrane rate, depth and rhythm understanding - To assess for interventions Changes of the Several - Assess pts general rapid or shallow given to and respiration that improve episodes of respiratory interventions condition given to occur because patients pallor fatigue improve of hypoxemia condition. - Auscultate breath Secondary patients Tachypnea to Pleural sounds, note areas of and stress condition. Long term: decreased/adventitious Effusion breath sounds as well - To note for Restlessness Long term: as fremitus etiology The patient precipitating shall manifest nasal flaring After 1-2 factors that can no signs of - Elevate head of the days of lead to impaired respiratory depth of Assessment

breathing Use of accessory muscles for breathing The pt. may manifest the ff: Confusion Cyanosis Diaphoresis

nursing pt. gas exchange distress. interventions, the pt. will - Note for presence of -To evaluate demonstrate cyanosis degree of improved compromise ventilation -Encourage frequent and adequate position changes and - To enhance oxygenation deep-breathing lung expansion of tissues exercises AEB absence - To assess of symptoms -Provide supplemental inadequate of respiratory oxygen at lowest systemic distress. concentration oxygenation or indicated by hypoxemia laboratory results and client symptoms/ -To promote situation optimum chest expansion - Review laboratory results To correct/ improve - Provide health existing teaching on how to deficiencies alleviate pts condition - To determine pts Administer prescribed oxygenation medications as status ordered - To empower SO and pt For the pharmacological management of the patients condition

4 Acute Pain
Pain may be considered as Pleuritic chest pain. Pleuritic chest pain derives from inflammation of the parietal pleura, the site of pleural pain fibers. Occasionally, this symptom is accompanied by an audible or palpable pleural rub, reflecting the movement of abnormal pleural tissues.

Nursing Nursing InterExpected Planning Rationale Dx ventions Outcome Subjective: Acute Short Term: Assess patient To identify Short Term: pain pain for intensity, (none) After 3-4 Patient shall intensity using precipitating factors hours of have a pain rating and location to nursing verbalized a Objective: scale, for assist in accurate interventions, decrease in location and diagnosis. the patients pain from a Patient for pain will Assessing response scale of 7 to manifested: precipitating decrease determines 3. factors. from 7 to 3 effectiveness of (+) DOB as verbalized Assess the medication and Long Term: by the response to whether further Complains to patient. medications interventions are The patient chest pain on every 5 required. shall have the minutes Long Term: demonstrated thoracostomy To provide activities and site Provide nonpharmacological behaviors After 2-3 comfort pain management. that will days of Facial measures. nursing prevent the grimaces interventions, A quiet recurrence of upon the patient Establish a environment pain. movement will quiet reduces the energy demonstrate environment. demands on the Reports of activities and patient. pain on the behaviors Elevate head of thoracostomy that will bed. Elevation improves area, prevent the chest expansion and described as recurrence of Monitor vital oxygenation. sharp pain. signs, provoked by especially Tachycardia and breathing pulse and elevated blood nonblood pressure, pressure usually radiating, every 5 occur with angina with a pain minutes until and reflect scale of 7 out pain subsides. compensatory of 10 mechanisms Teach patient secondary to Patient may sympathetic relaxation manifest: techniques and nervous system stimulation. how to use Restlessness them to reduce stress. Anginal pain is Confusion often precipitated by emotional stress Assessment

Irritability

that can be relieved nonpharmacological measures such as relaxation.

3 Activity Intolerance
Presence of a space-occupying liquid in the pleural space, the lung recoils, inward, the chest wall recoils outward, and the diaphragm is depressed inferiorly. This may lead to decrease lung volume and may result to significant hypoxemia and can only be relieved by thoracentesis. Due to inadequate ventilation there would be limitations in activity as tolerance to activity may occur.

Assessment Subjective: (none) Objective: Patient manifested: generalized weakness limited range of motion as observed use of accessory muscles during breathing (+) DOB

Nursing Diagnosis Activity intolerance related to insufficient oxygen for activities of daily living

Expected Outcome Short Term: To gain clients Short Term: participation After 3-4 hours The patient and of nursing Monitor and shall have cooperation in interventions, record Vital used the nurse the patient will Signs identified patient use identified techniques to interaction techniques to Assess patients improve improve To obtain activity general condition activity baseline data intolerance intolerance Adjust clients daily activities To note for any Long Term: Long Term: abnormalities and reduce intensity of level. and The patient deformities After 2-3 days Discontinue shall have present within reported of nursing activities that interventions, cause undesired the body measurable the patient will psychological increase in report changes To prevent activity measurable strain and intolerance. increase in overexertion Instruct client in activity unfamiliar intolerance. activities and in To conserve alternate ways of energy and conserve energy promote safety Planning Rationale Encourage to relax the

Nursing Interventions Establish Rapport

patient to have body adequate bed rest and sleep to provide relaxation Provide the patient with a to prevent risk calm and quiet for falls that environment could lead to injury Assist the client in ambulation fatigue affects both the Note presence of clients actual factors that could and perceived contribute to ability to fatigue participate in activities Ascertain clients ability to stand to determine and move about current status and degree of and needs assistance needed associated with or use of participation in equipment needed or desired activities Give client information that provides to sustain evidence of daily motivation of or weekly client progress to enhance Encourage the sense of well client to maintain being a positive attitude to promote Assist the client easy breathing in a semi-fowlers position to maintain an open airway Elevate the head of the bed to prevent injuries Assist the client in learning and to avoid risk demonstrating

appropriate safety for falls measures to help Instruct the SO minimize not to leave the frustration and client unattended rechannel energy Provide client with a positive to indicate atmosphere need to alter activity level Instruct the SO to monitor response of patient to an activity and recognize the signs and symptoms