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NCP Airway

The patient was experiencing difficulty breathing, sharp chest pain with breathing, productive cough with streaks of blood, shortness of breath, and use of accessory muscles. Vital signs showed tachycardia and bilateral pleural effusion was seen on CT scan. The nursing diagnosis was impaired gas exchange related to ineffective breathing pattern related to pleural inflammation. Interventions included monitoring vitals, administering medications, oxygen therapy, intravenous fluids, positioning, and encouraging deep breathing and coughing exercises to improve breathing and clear secretions.

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555 views2 pages

NCP Airway

The patient was experiencing difficulty breathing, sharp chest pain with breathing, productive cough with streaks of blood, shortness of breath, and use of accessory muscles. Vital signs showed tachycardia and bilateral pleural effusion was seen on CT scan. The nursing diagnosis was impaired gas exchange related to ineffective breathing pattern related to pleural inflammation. Interventions included monitoring vitals, administering medications, oxygen therapy, intravenous fluids, positioning, and encouraging deep breathing and coughing exercises to improve breathing and clear secretions.

Uploaded by

jlucando
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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NCP PROPER # 1 EXPLANATION OF THE NSG DOAGNOSIS S> Nahihirapan akong Ineffective breathing huminga, parang may pattern

occurs when sumasakal sa akin, tsaka inspiration and expiration marami akong plema. does not provide adequate ventilation. O> With RR of 28 cpm Pleural inflammation > Difficulty of breathing causes sharp pain upon noted deep breathing, > With ongoing coughing and moving. inhalation at full level This can result to LPM via face mask shallow or rapid > With productive cough breathing pattern. characterized as clear with streak of blood Impaired gas exchange amounting to 1 tbsp is a state in which there > Shortness of breath is excess or deficit noted oxygenation and carbon > Use of accessory dioxide elimination. The muscles upon breathing compensatory noted mechanism of lungs is to > Patient is unable to lose effectiveness of its tolerate moderate defense mechanism and fowlers position allow organisms to > With rhonchi and penetrate the lower crackles on both lung respiratory tract where fields upon auscultation inflammation develops. > CT-scan result as of 12/05/11 revealed bilateral pleural effusion > Nasal flaring noted > With capillary refill of 1-2 seconds PROBLEM OBJECTIVE STO: After 8 hours of nursing interventions, the patient will be able to demonstrate improvement of airway patency as evidenced by adequate oxygenation by pulse oximetry & blood gas analysis and effective coughing exercises. LTO: After 3 days of nursing interventions, the patient will be able to apply techniques that will improve breathing pattern and will be free from signs of respiratory distress: respiratory rate is within normal range, absence of cyanosis, effective breathing and minimal use of accessory muscles during breathing. INTERVENTION Dx> monitor vital signs RATIONALE >Monitoring the changes in vital signs is important because it may indicate if a condition becomes worst. (J. Fuzy) > Lesser amount of output than intake may indicate fluid retention. (L. white, 2005) > Respiratory status assessment helps gauge the severity or whether it is progressing. (L. White, 2005) >Circulatory status indicates proper perfusion and oxygenation of patient. (J.L. Vincent, 2010) > Characteristics involve color and amount which indicate problem in the lungs and tracheobronchial tree. (Lippincott Williams and Wilkins, 2006) >A mucolytic agent that breakdown acid mucopolysaccharide fibers making the sputum thinner and less viscous EVALUATION

> Monitor intake and output

> Assess respiratory status

> Assess circulatory status

> Assess characteristics of cough

Tx> Administer ambroxol

> With pitting edema, +2 on right arm > Administer Levopront Nsg Diagnosis: Impaired Gas Exchange related to Ineffective Breathing Pattern related to

> Assist patient in sitting position

> Maintain oxygen therapy as ordered > Regulate IVF as ordered

and therefore easier to remove by coughing. > A cough suppressant that that suppresses the cough reflex by depressing the cough center (Mason, 2002) > To increase chest expansion and by law of gravity, abdominal organs will not compress the diaphragm. >To provide relief from symptoms of hypoxemia and hypoxia. > Over infusion will aggravate and exacerbate the effect of pleural effusion. > Slow but deep breathing allows air to enter the lungs and allow lungs to expand fully. (Lippincott Williams and Wilkins, 2006) >To effectively eliminate secretions. > To decrease oxygen requirement in the body caused by movement.

Edx>Encourage DBE

>Encourage coughing exercise > Encourage bed rest

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