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.