Ineffective-Breathing-Pattern PDF

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Care plan for perfusion...

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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. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

Expected Nursing InterNursing Rationale Planning Outcome ventions Diagnosis - To gain pt/ SO’s Short Term: Ineffective Short Term: - Establish Subjective: rapport trust and  Dyspnea Breathing After 3 hours The patient cooperation Pattern RT - Monitor and of nursing Objectives: shall have Decreased - To obtain demonstrated interventions record vital Lung signs baseline data appropriate the patient The patient Volume coping manifested the Capacity will behaviors and demonstrate - Assess breath - To note for following: as methods to respiratory evidenced appropriate sounds, improve coping respiratory rate, abnormalities  Tachypne by breathing behaviors and depth and that may indicate a tachypnea, pattern. methods to rhythm early respiratory  Presence presence of improve compromise and of crackles crackles on Long term: - Elevate head hypoxia on both lung both lung breathing pattern. of the pt. fields upon fields and - To promote The patient auscultation dyspnea Long term: - Provide lung expansion shall have  use of applied accessory relaxing techniques After 1 to 2 environment muscles - To promote that improved days of  RR of 28 adequate rest nursing periods to limit breathing Administer The patient may pattern and be interventions, supplemental fatigue manifest the free from the patient oxygen as following: signs and would be able ordered - To maximize to apply oxygen available symptoms of  Cyanosis respiratory techniques -Assisst client in for cellular  Orthopne distress AEB that would uptake the use of a respiratory improve relaxation  Diaphores breathing technique -To provide relief rate within is normal range, pattern and be of causative absence of free from factors - Administer cyanosis, signs and prescribed effective symptoms of medications as - For the respiratory ordered pharmacological breathing and distress. management of minimal use of accessory the patient’s -Maximize Assessment

respiratory effort with good posture and effective use if accessory muscles.

condition -To promote wellness

muscles during breathing.

- to limit fatigue

-Encourage adequate rest periods between activities

2 Impaired Gas Exchange Impaired gas exchange is a state in which there is excess or deficit oxygenation and carbon dioxide elimination. The compensatory mechanism of lungs is to lose effectiveness of its defense mechanisms and allow organisms to penetrate the sterile lower respiratory tract where inflammation develops. Disruption of mechanical defenses and ciliary motility leads to colonization of lungs and subsequent infection. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively. The release of endotoxins by the microbes can lodge in the brain, affecting the respiratory center in medulla resulting to altered oxygen supply.

Assessment Subjective: (none) Objective: The patient manifested Several episodes of pallor Tachypnea Restlessnes s

Nursing Planning Diagnosis Impaired Short term: Gas After 1 hour Exchange of nursing R/T Alveolar –Capillary interventions, Membrane the pt will verbalize Changes understandin and g of the respiratory interventions fatigue Secondary to given to improve Pleural patient’s Effusion condition. Long term:

Nursing Interventions - Establish rapport

Rationale

- To gain pt./SO’s trust - Monitor and record and vital signs cooperation

Expected Outcome Short term:

The patient shall have verbalized understandin - Monitor respiratory - To obtain g of the rate, depth and rhythm baseline data interventions given to To assess for - Assess pt’s general rapid or shallow improve condition respiration that patient’s occur because condition. - Auscultate breath sounds, note areas of of hypoxemia Long term: decreased/adventitiou and stress s breath sounds as - To note for The patient well as fremitus etiology shall manifest no signs of - Elevate head of the precipitating

nasal flaring depth of breathing Use of accessory muscles for breathing The pt. may manifest the ff: Confusion Cyanosis Diaphoresis

After 1-2 days of nursing interventions, the pt. will demonstrate improved ventilation and adequate oxygenation of tissues AEB absence of symptoms of respiratory distress.

factors that can respiratory lead to impaired distress. - Note for presence of gas exchange cyanosis -To evaluate -Encourage frequent degree of position changes and compromise deep-breathing - To enhance exercises lung expansion -Provide supplemental - To assess oxygen at lowest inadequate concentration systemic indicated by laboratory results and oxygenation or hypoxemia client symptoms/ situation -To promote - Review laboratory optimum chest expansion results pt.

- Provide health teaching on how to alleviate pt’s condition

To correct/ improve existing deficiencies

Administer prescribed - To determine pt’s oxygenation medications as status ordered - To empower SO and pt For the pharmacologica l management of the patient’s condition

4 Acute Pain

Pain may be considered as Pleuritic chest pain. Pleuritic chest pain derives from inflammation of the parietal pleura, the site of pleural pain fibers. Occasionally, this symptom is accompanied by an audible or palpable pleural rub, reflecting the movement of abnormal pleural tissues.

Nursing Nursing InterExpected Planning Rationale Outcome Dx ventions Subjective: Acute Short Term: Short Term: Assess patient To identify intensity, pain for pain (none) Patient shall After 3-4 intensity using precipitating factors have hours of a pain rating and location to verbalized a nursing Objective: assist in accurate scale, for decrease in interventions location and diagnosis. pain from a , the patient’s for Patient scale of 7 to Assessing response pain will manifested: precipitating 3. determines decrease factors. effectiveness of from 7 to 3 (+) DOB medication and as verbalized Assess the Long Term: whether further response to by the Complains to interventions are medications patient. The patient chest pain on required. every 5 shall have the minutes Long Term: demonstrate thoracostom To provide d activities y site nonpharmacologica Provide and After 2-3 l pain management. comfort behaviors days of Facial measures. that will nursing grimaces prevent the A quiet interventions upon recurrence of environment Establish a , the patient movement reduces the energy pain. quiet will demands on the environment. demonstrate Reports of patient. activities and pain on the behaviors Elevate head of thoracostom that will Elevation improves bed. y area, prevent the chest expansion and described as recurrence of Monitor vital oxygenation. sharp pain. signs, provoked by Tachycardia and especially breathing elevated blood pulse and nonblood pressure, pressure usually radiating, occur with angina every 5 with a pain and reflect minutes until scale of 7 out compensatory pain subsides. of 10 mechanisms secondary to Teach patient Patient may sympathetic relaxation manifest: techniques and nervous system how to use

Assessment

Restlessness Confusion Irritability

them to reduce stimulation. stress. Anginal pain is often precipitated by emotional stress that can be relieved nonpharmacological measures such as relaxation.

3 Activity Intolerance Presence of a space-occupying liquid in the pleural space, the lung recoils, inward, the chest wall recoils outward, and the diaphragm is depressed inferiorly. This may lead to decrease lung volume and may result to significant hypoxemia and can only be relieved by thoracentesis. Due to inadequate ventilation there would be limitations in activity as tolerance to activity may occur.

Nursing Planning Diagnosis Subjective: Activity Short Term: intolerance (none) After 3-4 related to hours of insufficient Objective: oxygen for nursing interventions, activities of the patient Patient daily living will use manifested: identified techniques to generalized improve weakness activity intolerance limited range of Long Term: motion as observed After 2-3 days of use of nursing accessory interventions, muscles the patient during

Assessment

Nursing Interventions Establish Rapport Monitor and record Vital Signs Assess patient’s general condition

Rationale To gain clients participation and cooperation in the nurse patient interaction

Expected Outcome Short Term:

The patient shall have used identified techniques to improve activity To obtain baseline data intolerance

Adjust client’s daily activities and reduce intensity of level. Discontinue activities that cause undesired To note for Long Term: psychological changes any abnormalities The patient and shall have Instruct client in deformities reported unfamiliar activities and in alternate ways present within measurable the body increase in of conserve energy activity Encourage patient to To prevent

breathing (+) DOB

will report measurable increase in activity intolerance.

intolerance. have adequate bed rest strain and overexertion and sleep To conserve Provide the patient with a calm and quiet energy and promote environment safety Assist the client in to relax the ambulation body Note presence of to provide factors that could contribute to fatigue relaxation to prevent Ascertain client’s risk for falls ability to stand and move about and degree that could of assistance needed or lead to injury use of equipment fatigue affects both the Give client client’s actual information that provides evidence of and perceived ability to daily or weekly participate in progress activities Encourage the client to to determine maintain a positive current status attitude and needs Assist the client in a associated semi-fowlers position with participation Elevate the head of the in needed or desired bed activities Assist the client in learning and demonstrating appropriate safety measures

to sustain motivation of client

to enhance Instruct the SO not to sense of well being leave the client unattended

Provide client with a positive atmosphere

to promote easy breathing

Instruct the SO to to maintain monitor response of patient to an activity an open and recognize the signs airway and symptoms to prevent injuries to avoid risk for falls to help minimize frustration and rechannel energy to indicate need to alter activity level...