5 NURSING CARE PLANS

1. Ineffective tissue perfusion (cardiopulmonary) related to impaired transportation of the oxygen across the alveolar and/or capillary membrane. 2. Imbalanced nutrition, less than body requirement related to illness. 3. Ineffective airway clearance related to retained secretions. 4. Impaired gas exchange related to alveolar-capillary membrane changes.
5. Acute Pain related to actual tissue damage resulting from inserted foreign object (CTT).

ASSESSMENT

NURSING DIAGNOSIS Ineffective tissue perfusion (cardiopulmonary) related to impaired transportation of the oxygen across the alveolar and/or capillary membrane.

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Galisod ko ug ginhawa as verbalized by the patient. Objective: - RR=26 cpm - Irritability - Restlessness

After 8 hours of care patient will be able to: a. Demonstrate behaviors/lifestyle changes to improve circulation. b. Demonstrate increased perfusion as individually appropriate.

Independent: -Identify changes related to systemic or peripheral alterations in circulation. -Determine duration of problem. -Monitor vital signs -Investigate report of chest pain Dependent: -Administer medication as ordered

-To assess contributing factors

After 8 hours of care Goals met. Patient was able to: a. Demonstrate behaviors/lifestyle - To note degree of changes to improve impairment circulation - To maximize b. Demonstrate tissue perfusion increased perfusion - To note degree of as impairment individually appropriate. -To maximize tissue perfusion

ASSESSMENT

NURSING DIAGNOSIS Acute Pain related to actual tissue damage resulting from inserted foreign object (CTT).

SCIENTIFIC BASIS Chest tube thoracostomy is done to drain fluid, blood, or air from the space around the lungs. Some diseases, such as pneumonia and cancer, can cause an excess amount of fluid or blood to build up in the space around the lungs (called a pleural effusion). Also, some severe injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung can be accidentally punctured allowing air to gather outside the lung, causing its collapse (called a pneumothorax)

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Magsakit-sakit ako dughan as verbalized by the patient. -with pain scale 8/10 Obejective: v/s T-36 P-84 R-36 BP-90/60

Short Term Goal: After 4 hours of nursing intervention the patient will be able to verbalize pain is decreased from 8/10 to 3/10.

Independent: 1.Monitor Vital signs Dependent: -Administer medication as ordered

-To assess contributing factors

After 8 hours of care Goals met. Patient was able to: a. Demonstrate behaviors/lifestyle - To note degree of changes to improve impairment circulation - To maximize b. Demonstrate tissue perfusion increased perfusion - To note degree of as impairment individually appropriate. -To maximize tissue perfusion

ASSESSMENT

NURSING DIAGNOSIS Imbalanced nutrition, less than body requirement related to illness.

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Wala koy gana mo kaon maam as verbalized by the patient. Objective: - Poor muscle tone - Pale -weight loss - Weakness

After 8 hours of care patient will be able to demonstrate progressive good appetite.

Independent: -Identify underlying condition involved. -Identify clients at risk for malnutrition. - Discuss eating habits, including food preferences, intolerance. -Assess weight, age, body build, and strength of the client. Dependent: -Administer pharmaceutical agents as indicated.

-To assess causative factors.

After 8 hours of care Goals met. Patient was able to - to assess demonstrate contributing factors. progressive good appetite. -To appeal to clients like and dislike. - To evaluate degree of deficit.

-To evaluate degree deficit.

ASSESSMENT

NURSING DIAGNOSIS

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Ga sige rako ug ubo-ubo sir as verbalized by the patient. Objective: - cough - restlessness - yellowish sputum - tachycardia (PR=107 bpm) - pale - RR=26 cpm

Ineffective airway clearance related to retained secretions.

After 8 hours of care, patient will be able to: a. maintain airway patency b. expectorate/ clear secretions readily.

Independent: - Elevate head of the bed/change position every 2 hours. - Encouraged deep-breathing and coughing exercises. - Auscultate breath sounds and assess air movement. - Evaluate changes in sleep pattern.

-To take advantage of gravity decreasing pressure on the diaphragm. -To mobilize secretions.

-To ascertain status and note progress. -To assess changes.

After 8 hours of care Goals partially met. Patient was able to: a. Maintain airway patency. b. Expectorate clear secretions readily as evidenced by less secretions retained.

ASSESSMENT

NURSING DIAGNOSIS Impaired gas exchange related to alveolarcapillary membrane changes.

SCIENTIFIC BASIS Pleural Effusion is collection of fluid in the pleural space of the lungs. Fluid normally resides in the pleural space and acts as a lubricant for the pleural membranes to slide across one another when we breathe. Fluid is constantly being added and reabsorbed by capillaries and lymph vessels in the pleura. When this recycling process is interrupted, a pleural effusion can result.

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Galisud ko ug ginhawa kung mahago ko ug ubo as verbalized by the patient. Objective: - RR=26 - Dyspnea - Restlessness - Tachycardia (PR=107 bpm) - Pale

After 8 hours of care patient will be able to: a. Participate in treatment regimen b. Demonstrate improve ventilation.

Independent: - To evaluate - Monitor vital signs degree of compromise. - Elevate head of bed/position client - To maintain appropriately. airway.

After 8 hours of duty goals not met.

Patient was not able to: a. Participate in - Maintain adequate - For mobilization of treatment regimen. I/O. secretions. b. Demonstrate Encourage frequent - To improve ventilation. position correct/improve changes and deep- existing condition breathing coughing exercises. deficiencies. Dependent: - Administer medications as indicated. -02 prn 24litres/min

-To treat underlying conditions.