PATIENT:X

STATEMENT OF THE
PROBLEM

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

OBJECTIVE:
Dyspnea
Observed physical
discomfort

AFE:17Y/O

DX:PLEURAL EFFUSION

NURSING
DIAGNOSIS

BACKROUND OF THE
STUDY

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

use of accessory
muscle noted

Atelectasis in the affected

side of the lung

oxygen in use via

nasal cannula, 23L/min

mucus/secretion

Impaired cardiac
filling/inflamed pleural
membranes
(intensified on inspiration)

production

Dyspnea, difficulty in

Gamotin
Trixie 1

GOAL

LONG TERM
OUTCOME:

INTERVENTION

RATIONALE

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

Respiratory rate and

rhythm changes are
early warning signs of
impending respiratory
difficulties.

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

these signify an
increase in work of
breathing

SHORT TERM
OUTCOME:

position client with

proper body
alignment(semi-fowlers
position)

After 2 days of
nursing intervention,
the client will be able
to:

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

demonstrate

pace and schedule

This is for good lung

excursion and chest
expansion

this provides
adequate oxygenation
to prevent patient from
desaturation

EVALUATION

LONG TERM
OUTCOME
ACHIEVED:
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.

SHORT TERM
OUTCOME
ACHIEVED:
After 4 hours of
nursing intervention,
the client will be able
to:
verbalize awareness
of causative factors

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)

This prevents
dyspnea resulting
from fatigue
these promote deep
inspiration

Teach client
appropriate deep
breathing and coughing
techniques

COLLABORATIVE:
Administer oxygen at
lowest concentration
indicated

Refer the client to a

dietician and or support
groups.

Gamotin
Trixie 2

these facilitate
adequate clearance of
secretions

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

demonstrate
appropriate coping
behaviors like proper
breathing and
coughing

PATIENT:X

Gamotin
Trixie 3

AFE:17Y/O

DX:PLEURAL EFFUSION