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    Subjective: Ventilation Assistance

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    Jobelle Acena
    The patient presented with shortness of breath, chest pain, cyanosis, and abnormal vital signs and ABG results. Based on the subjective and objective findings, the nursing diagnosis was determined to be ineffective breathing pattern related to decreased lung expansion due to an accumulation of air in the pleural space (pneumothorax). The nursing interventions included administering supplemental oxygen, monitoring ABGs and vital signs, assisting with breathing techniques, administering analgesics, and ensuring proper care of any chest tubes. The goals were for the patient to establish a normal breathing pattern and for ABG and vital sign results to improve within 4 hours.

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    Subjective: Ventilation Assistance

    Uploaded by

    Jobelle Acena
    3K views3 pages
    The patient presented with shortness of breath, chest pain, cyanosis, and abnormal vital signs and ABG results. Based on the subjective and objective findings, the nursing diagnosis was determined to be ineffective breathing pattern related to decreased lung expansion due to an accumulation of air in the pleural space (pneumothorax). The nursing interventions included administering supplemental oxygen, monitoring ABGs and vital signs, assisting with breathing techniques, administering analgesics, and ensuring proper care of any chest tubes. The goals were for the patient to establish a normal breathing pattern and for ABG and vital sign results to improve within 4 hours.

    Original Title

    NCP PNEUMOTHORAX

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    The patient presented with shortness of breath, chest pain, cyanosis, and abnormal vital signs and ABG results. Based on the subjective and objective findings, the nursing diagnosis was determined to be ineffective breathing pattern related to decreased lung expansion due to an accumulation of air in the pleural space (pneumothorax). The nursing interventions included administering supplemental oxygen, monitoring ABGs and vital signs, assisting with breathing techniques, administering analgesics, and ensuring proper care of any chest tubes. The goals were for the patient to establish a normal breathing pattern and for ABG and vital sign results to improve within 4 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    3K views3 pages

    Subjective: Ventilation Assistance

    Uploaded by

    Jobelle Acena
    The patient presented with shortness of breath, chest pain, cyanosis, and abnormal vital signs and ABG results. Based on the subjective and objective findings, the nursing diagnosis was determined to be ineffective breathing pattern related to decreased lung expansion due to an accumulation of air in the pleural space (pneumothorax). The nursing interventions included administering supplemental oxygen, monitoring ABGs and vital signs, assisting with breathing techniques, administering analgesics, and ensuring proper care of any chest tubes. The goals were for the patient to establish a normal breathing pattern and for ABG and vital sign results to improve within 4 hours.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
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    The key takeaways are that a pneumothorax occurs when air enters the pleural space due to a breach in the pleural membrane causing respiratory distress. Nursing interventions include oxygen supplementation, analgesia, positioning and monitoring of vital signs and ABGs.

    Signs and symptoms of pneumothorax include dyspnea, tachypnea, cyanosis, decreased breath sounds, hyperresonance and respiratory distress.

    Nursing interventions for pneumothorax include administering supplemental oxygen, assisting with splinting and positioning, administering analgesics and sedatives, and monitoring vital signs and ABGs to assess response to therapy.

    ASSESSMENT NURSING INFERENCE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION

    DIAGNOSIS
    Ventilation Assistance:
    Subjective: Ineffective A pneumothorax After 4 hours of Administer supplemental Aids in reducing work of After 4 hours of
    “Sumisigaw siya, Breathing is the collection nursing oxygen via cannula, breathing; promotes relief nursing
    nung makita ko siya Pattern may of air between intervention, mask, or mechanical of respiratory distress and interventions, the
    nakahiga siya sa be related to the visceral and the patient will ventilation, as indicated. cyanosis associated with patient was able to
    sahig at duguan sa decreased lung parietal pleura establish a hypoxemia. establish a normal or
    kanang dibdib niya, expansion due (pleural space) normal or effective respiratory
    naghahabol siya ng to air or fluid due to a breach effective Monitor and graph serial Assesses status of gas pattern with ABGs
    hininga at sumasakit accumulation of either the respiratory ABGs and pulse exchange and ventilation within normal range
    amg kanyang as evidenced visceral or pattern with oximetry. Review vital and need for continuation and absence of
    dibdib” as by dyspnea, parietal pleura. A ABGs within capacity and tidal or alterations in therapy. cyanosis and other
    verbalized by his tachypnea, pneumothorax patient’s normal volume measurements.  signs and symptoms
    spouse. cyanosis, and may develop range and be of hypoxia.
    Objective: abnormal spontaneously or free of cyanosis Assist patient with Supporting chest and
    ABGs. secondary to and other signs splinting painful area abdominal muscles make
     Cyanosis another and symptoms when coughing, deep coughing more effective
     Decreased vocal condition. of hypoxia breathing. and less traumatic.
    fremitus Trauma to the
     Hyperresonant chest wall or Maintain a position of Promotes
     diminished pleura disrupts comfort, usually with the maximal inspiration;
    breath sounds the pleural head of bed elevated. enhances lung expansion
     Respiratory membrane. Open Turn to the affected side. and ventilation in
    distress occurs with Encourage patient to sit unaffected side.
     Tachypneic penetrating chest up as much as possible.
     Tachycardic trauma that
    allows air from Administer analgesics Given to manage pleuritic
     Hypertension
    the environment and sedatives, as pain and reduce anxiety and
    to enter the indicated. tachycardia associated with
    T: 37 ℃
    P: 110 bpm pleural space.. impaired respiratory
    R: 30 breathes/min function, especially when
    BP: 140/90 mmHg client is on a ventilator.
    Tube Care: Chest
    ABG: 5 If thoracic catheter is
    disconnected or
    pH: 7.50
    dislodged: Observe for Pneumothorax may recur,
    PaO2: 70 mmHg signs of respiratory requiring prompt
    distress. If possible, intervention to prevent
    PaCO2: 29 mmHg
    reconnect thoracic fatal pulmonary and
    SpO2: 80% catheter to tubing and circulatory impairment.
    suction, using clean
    HCO3: 20mEq/L
    technique. If the
    catheter is dislodged
    Respiratory
    from the chest, cover
    alkalosis with
    insertion site
    hypoxemia
    immediately with
    petrolatum dressing and
    apply firm pressure.
    Notify physician at once.

    After thoracic catheter is


    removed: Cover Early detection of a
    insertion site with sterile developing complication,
    occlusive dressing. such as recurrence of
    Observe for signs or pneumothorax or presence
    symptoms that may of infection, is essential.
    indicate recurrence of
    pneumothorax, such as
    shortness of breath and
    reports of pain. Inspect
    insertion site, noting
    character of drainage.

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