Careplan
Nursing Diagnosis Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleuralcavity Nursing Plan Objectives : Patients able to maintain normal lung function
Criterion Results : Rhythm, frequency and depth of breathing in the normal range, the chest X-ray examinations didnot find any accumulation of fluid, audible breath sounds. Plan of action :
Identify the causative factor.Rational: By identifying the causes, we can determine which type of pleural effusi can take appropriate action.
Examine the quality, frequency and depth of breathing, report any changes that occur.Rational: By reviewing the quality, frequency and depth of breathing, we can determine how far the patient's conditionchanges.
Lay the patient in a comfortable position, in a sitting position, with the head of the bed elevated 60 to 90 degrees.Rational: Decrease the diaphragm to expand the chest so the lungs can expand the maximum.
Observation of vital signs (temperature, pulse, blood pressure, RR and response of patients).Rational: Improved tachcardi RR and an indication of decline in lung function.
Perform auscultation of breath sounds every 2-4 hours.Rational: to determine abnormalities Auscultation of breath sounds in the lungs.
Help and teach the patient to cough and breath in effective.Rational: Pressing the painful area when coughing or breathing deeply. Emphasis pectoral muscle and abdominalmakes cough more effective.
Collaboration with other medical teams to deliver O2 and medicines as well as thorax images.Rational: Giving oxygen may reduce the load and prevent the occurrence of respiratory cyanosis due hiponia. Withthe thorax images can be monitored the progress of the reduction in fluid and the return offlower power
Criterion Results : Rhythm, frequency and depth of breathing in the normal range, the chest X-ray examinations didnot find any accumulation of fluid, audible breath sounds. Plan of action :
Identify the causative factor.Rational: By identifying the causes, we can determine which type of pleural effusi can take appropriate action.
Examine the quality, frequency and depth of breathing, report any changes that occur.Rational: By reviewing the quality, frequency and depth of breathing, we can determine how far the patient's conditionchanges.
Lay the patient in a comfortable position, in a sitting position, with the head of the bed elevated 60 to 90 degrees.Rational: Decrease the diaphragm to expand the chest so the lungs can expand the maximum.
Observation of vital signs (temperature, pulse, blood pressure, RR and response of patients).Rational: Improved tachcardi RR and an indication of decline in lung function.
Perform auscultation of breath sounds every 2-4 hours.Rational: to determine abnormalities Auscultation of breath sounds in the lungs.
Help and teach the patient to cough and breath in effective.Rational: Pressing the painful area when coughing or breathing deeply. Emphasis pectoral muscle and abdominalmakes cough more effective.
Collaboration with other medical teams to deliver O2 and medicines as well as thorax images.Rational: Giving oxygen may reduce the load and prevent the occurrence of respiratory cyanosis due hiponia. Withthe thorax images can be monitored the progress of the reduction in fluid and the return offlower power