PATIENT:X STATEMENT OF THE PROBLEM

AFE:17Y/O NURSING DIAGNOSIS

DX:PLEURAL EFFUSION BACKROUND OF THE STUDY GOAL INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: Stated: Nahihirapan akog huminga at saka kinakapos ako sa paghinga.

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.

INDEPENDENT: Assess respiratory rate and depth by listening to lung sounds.

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

this provides adequate oxygenation to prevent patient from desaturation

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

demonstrate appropriate coping behaviors like proper breathing and coughing

COLLABORATIVE: Administer oxygen at lowest concentration indicated

these facilitate adequate clearance of secretions

For management of underlying pulmonary condition and respiratory distress. --.for proper counseling and intake of caloric needs.

Refer the client to a dietician and or support groups.

Gamotin Trixie 2

PATIENT:X

AFE:17Y/O

DX:PLEURAL EFFUSION

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