1 Ineffective Breathing Pattern

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Nursing Diagnosis Ineffective breathing pattern related to decreased lung expansion secondary to accumulation of fluid in the pleural cavity 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 did not find any accumulation of fluid, audible breath sounds. Plan of action :
y

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 condition changes.

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 abdominal makes 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. With the thorax images can be monitored the progress of the reduction in fluid and the return of flower power lung.

y y y y y y

NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING

y y y y y

INTERVENTION RATIONALE EVALUATION

y y y

Subjective: Masakit ang dibdib ko as verbalized by patient. Objective:

Use of accessory muscle.

y y y y y y y y

Dyspnea

Fatigue.

V/S taken as follows: T: 37.3 P: 80 R: 25 Bp: 120/80 Acute pain r/t localized inflammation and persistent cough.

y y

Pneumonia is inflammation of the terminal airways and alveoli caused by acute infection by various agents. Pneumonia can be divided into three groups: community acquired, hospital or nursing home

acquired (nosocomial), and pneumonia in an immunocompr omised person. Causes include bacteria (Streptococcu s, Staphylococcu s,
y y y y

y y y

After 4 hours of nursing interventions , the patient will display patent airway with breath sounds clearing and absence of dyspnea. Independent:

Elevate head of the bed, change position frequently.

y y

Assist patient with deep breathing exercises.

y y

Demonstrate or help patient learn to perform activity like splinting chest

and effective coughing while in upright position. y y

Force fluids to at least 3000 ml per day and offer warm, rather than cold fluids.

y y

y y y

Lowers diaphragm, promoting chest expansion and expectoration of secretions.

Deep breathing facilitates maximum expansion of the lungs and smaller airways.

y y

Coughing is a natural self cleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.

y y

Fluids especially warm liquids aid in

mobilization and expectoration of secretions. y y

After 4 hours of nursing intervention s, the patient was able to display patent airway with breath sounds clearing and absence of dyspnea.

aemophilus influenzae, Klebsiella, Legionella). Community Acquired Pneumonia (CAD) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs. It is an acute inflammatory condition thats result from aspiration of

y y y

y y

y y

y y

oropharyngeal secretions or stomach contents in the lungs. Collaborative: Administer medications as prescribe: mucolytics or expectorants. Provide supplemental fluids. Aids in reduction of bronchospas m and mobilization of secretions. Fluids are required to replace losses and aid in mobilization of secretions.