Patient B is a 67 years old male and has been diagnosed with Pneumothorax secondary to Vehicular Accident.

With CTT connected to water seal drainage. ASSESSMENT DIAGNOSIS Subjective Data: Nahihirapan ako huminga Tumusok kasi yung sarili kong buto sa baga ko, kaya eto inaalis nila yung namuong dugo sa baga ko As manifested by the patient. Objective Data: With chest thoracostomy connected to water seal chamber at Right, Bradypnea Temp: 36.7C RR: 14 bpm BP: 130/90 mm/Hg PR: 79 cpm Ineffective breathing pattern related to airway obstruction secondary to Pneumothorax. PLANNING After 8 hours of shift: Independent Intervention: 1. Monitor rate, Goal: rhythm, and depth The patient of respiration. Note will be able breathing to establish a irregularities, for normal, example, apneustic, effective ataxic, or cluster respiratory breathing. pattern as 2. Note competence evidenced by of gag and swallow increase reflexes and respiratory clients ability to rate. The protect own patient will airway. verbalize the understanding 3. Elevate head of of smoking free lifestyle. bed as permitted and position on Objective: sides, as indicated. The patient will be able 4. Encourage deep breathing if client to demonstrate is conscious 5. Auscultate breath breathing sounds, noting exercises to promote lung areas of hypoventilation and expansion. presence of adventitious sounds. 6. Monitor use of respiratory depressant drugs, such as sedatives. 7. Instruct the patient to avoid over-eating and gas forming foods. 8. Maintain calm attitude while

INTERVENTION RATIONALE EVALUATION >Changes may indicate onset of pulmonary complications. >Ability to mobilize or clear secretions is important to airway maintenance. Loss of swallow or cough reflex may indicate need for artificial airway or intubation. > Facilitates lung expansion and ventilation, and reduces risk of airway obstruction by tongue. > Prevents or reduces atelectasis. >Identifies pulmonary problems such as atelectasis, congestion, and airway obstruction, which may jeopardize Goal met: The patients respiratory rate is increased (RR: 18 bpm) The patient is able to demonstrate breathing exercises. And the patient is able to verbalize his understanding of smoking free lifestyle.

dealing with the patient

cerebral oxygenation. >Can increase Dependent respiratory Intervention: embarrassment Administer pain and killer/sedative/anti- complications. pyretic as prescribed by the >To avoid doctor. abdominal distension Collaborative intervention: >To limit Assist in level of Reclogging of the anxiety CTT Assist the patient in >To Follow developing plan of patients smoking cessation therapeutic (Inform the patient regimen to about the adverse stabilize her and side effects of wellness of smoking. health. >To promote maximum inspiration. >To promote faster healing and to promote patients optimal health.