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OBJECTIVE: Dyspnea Observed physical discomfort use of accessory muscle noted oxygen in use via nasal cannula, 23L/min mucus/secretion production
INEFFECTIVE BREATHING PATTERN RELATED TO TRACHEOBRONCHIAL OBSTRUCTION SECONDARY TO PLEURAL EFFUSION AS EVIDENCED BY DYSPNEA
Tracheobronchial obstruction Amounts of fluid are drained from the pleural cavity fluid pressure in the pleural cavity Atelectasis in the affected side of the lung Impaired cardiac filling/inflamed pleural membranes (intensified on inspiration) Dyspnea, difficulty in
LONG TERM OUTCOME: After 2 days of nursing intervention, the client will be able to: Establish a normal/effective respiratory pattern AEB absence of s/s of hypoxia, normal skin color.
Note muscles used for breathing(sternocleidomastoid, diaphragmatic) and retractions/flaring of nostrils position client with proper body alignment(semi-fowlers position)
LONG TERM OUTCOME Respiratory rate and ACHIEVED: rhythm changes are After 2 days of early warning signs of impending respiratory nursing intervention, the client will be able difficulties. to: these signify an Establish a increase in work of normal/effective breathing respiratory pattern AEB absence of s/s of hypoxia, normal skin color. This is for good lung excursion and chest expansion
SHORT TERM OUTCOME: After 4 hours of nursing intervention, the client will be able to: verbalize awareness of causative factors demonstrate
SHORT TERM OUTCOME ACHIEVED: After 4 hours of nursing intervention, the client will be able to: verbalize awareness of causative factors
Ensure that oxygen delivery system is applied to the patient, the appropriate amount of oxygen is delivered pace and schedule
Gamotin Trixie 1
PATIENT:X
AFE:17Y/O
DX:PLEURAL EFFUSION breathing, altered chest appropriate coping excursion, respiratory behaviors like proper depth changes breathing and coughing Reference: Medical Surgical Nursing:Brunner 11th edition, p.652
activities providing adequate rest periods Encourage sustained deep breaths by emphasizing slow inhalation, holding end inspiration) Teach client appropriate deep breathing and coughing techniques
This prevents dyspnea resulting from fatigue these promote deep inspiration
For management of underlying pulmonary condition and respiratory distress. --.for proper counseling and intake of caloric needs.
Gamotin Trixie 2
PATIENT:X
AFE:17Y/O
DX:PLEURAL EFFUSION
Gamotin Trixie 3