Nursing

Assessment Planning Intervention Rationale Evaluation

Diagnosis
Subjective Data: Ineffective Short-term Goals: Independent: Short-term Goals:
“Hinihingal lang Breathing Pattern After 30-60 - Establish rapport - To facilitate
ako pero walang related to Excess minutes of Nursing cooperation as well Goal partially met
masakit” as fluid buildup in the Intervention the as to gain patient’s After 30-60
verbalized by the pleura as evidenced patient will be able trust minutes of Nursing
patient by patient’s to: Intervention the
verbalization, - achieve an - Monitor and - To obtain baseline patient was able to:
Objective Data: tachypnea, O2 effective record vital signs data - achieve an
- RR: 22cpm support, and nasal breathing oxygen
(tachypnea) flaring pattern as - Assess breath - To note for saturation
- O2 support evidenced sounds, respiratory respiratory above 95%
at 3 Lpm via by a rate, depth and abnormalities that - verbalize
NC respiratory rhythm may indicate early ease of
- Nasal rate of 12- respiratory breathing
Flaring 20 bpm and compromise and “May higal
oxygen hypoxia pa din pero
saturation konti
above 95% - Elevate the - Elevating the head
nalang”
patient’s head of of the bed can
- verbalize the bed improve lung
ease of expansion and help Long-term Goals:
breathing open up the airways Goal Met
enabling air to pass After 2days of
through with less Nursing
obstruction making Intervention the
Long-term Goals: it easier to breathe patient will be able
After 2days of to:
Nursing - Encourage patient - To promote lung - Maintained
Intervention the to perform deep expansion an effective
patient will be able breathing exercises breathing
to: pattern as
- Maintained - Provide relaxing - To promote evidenced
an effective environment adequate rest by a
breathing periods to limit respiratory
pattern as fatigue rate of 20
evidenced cpm and
by a - Prepare the patient - Thoracentesis oxygen
respiratory for thoracentesis may relieve saturation of
rate of 12- pressure from fluid 98%
20 bpm and on the lungs
oxygen treating symptoms
saturation such as pain and
above 95% shortness of breath

Dependent:
- Administer - Providing
oxygen therapy as supplemental
prescribed oxygen is essential
to prevent cellular
hypoxia caused by
low oxygen
secondary to
ineffective
breathing patterns
 Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Subjective Data: Risk for Short Term Goals Independent: GOAL MET
No subjective cues Infection related After 30 minutes to 1 -Monitor Vital -To have baseline Short Term Goals
to thoracentesis, hour of Nursing signs data, note fever, After 30 minutes to 1
Objective Data: paracentesis Intervention the tachycardia, or hour of Nursing
- with procedure and client will be able to: changes in blood Intervention the
wound pigtail insertion 1. Understand pressure depending client was able to:
dressing the causative on the extent of the 1. Understand
dry and factors that infection the causative
intact may factors that
- with pigtail contribute to may
catheter infection -Monitor for signs -Increased white contribute to
2. Demonstrate of infection blood cell count, infection
the techniques Fever, Redness,
2. Demonstrate
in preventing swelling, purulent
infection and drainage of areas the techniques
proper of non-intact skin, in preventing
dressing of and Changes in infection and
the operative urine or sputum. proper
site Early identification dressing of
3. Patient of infection allows the operative
verbalizes for prompt site
understanding treatment 3. Patient
of behavioral verbalizes
and hygiene -Encourage to -Aseptic technique understanding
measures to maintain strict decreases the of behavioral
prevent asepsis for dressing chances of and hygiene
infection. changes, wound transmitting or measures to
4. Patient care spreading prevent
verbalizes pathogens to or infection.
recognition of between patients. 4. Patient
signs of Interrupting the verbalizes
 infection that chain of infection recognition of
need to be is an effective way signs of
reported to a to prevent the infection that
healthcare spread of infection need to be
provider for reported to a
treatment. -Encourage intake -Proper nutrition healthcare
of protein-rich and and a balanced diet
provider for
Long term Goal calorie-rich foods support the
treatment.
After 2-3 hours of and encourage a immune systems’
Nursing Intervention balanced diet. responsiveness and
the patient will be: enhance the health GOAL MET
1. Free of of all the body’s Long term Goal
infection as tissues. Adequate After 2-3 hours of
evidenced by nutrition enables Nursing Intervention
vital signs the body to the patient was able
within normal maintain and to:
range and rebuild tissues and 1. Free of
lack of helps keep the infection as
evidence of immune system evidenced by
infection such functioning well vital signs
as swelling, within normal
redness, and -Encourage -Fluids help range and
purulent increased fluid promote diluted lack of
drainage from intake unless urine, frequent evidence of
non-intact contraindicated emptying of the infection such
areas of skin bladder, and as swelling,
reducing the stasis redness, and
of urine. This purulent
ultimately reduces drainage from
the risk of bladder non-intact
infection or urinary areas of skin
tract infection.
Increased fluid
 intake also helps
replace fluid lost
during fever and
helps thin
secretions

-Encourage sleep -Adequate sleep is

and rest an essential
modulator of
immune responses.
A lack of sleep can
weaken immunity
and increased
susceptibility to
infection

Dependent:
-Administer -used to treat
Azithromycin bacterial infections
(Zithromax) as
prescribed
 Thoracentesis
Thoracentesis is a procedure to remove fluid or air from around the lungs. A needle is put through
the chest wall into the pleural space. The pleural space is the thin gap between the pleura of the
lung and of the inner chest wall. The pleura is a double layer of membranes that surrounds the
lungs. Inside the space is a small amount of fluid. The fluid prevents the pleura from rubbing
together when you breathe. Excess fluid in the pleural space is called pleural effusion. When this
happens, it’s harder to breathe because the lungs can’t inflate fully. This can cause shortness of
breath and pain. These symptoms may be worse with physical activity.
What happens during thoracentesis?
The way the procedure is done may vary. It depends on your condition and your healthcare
provider's methods. In most cases, a thoracentesis will follow this process:
- You may be asked to remove your clothes. If so, you will be given a hospital gown to wear.
You may be asked to remove jewelry or other objects.
- You may be given oxygen through a nasal tube or face mask. Your heart rate, blood
pressure, and breathing will be watched during the procedure.
- You will be in a sitting position in a hospital bed. Your arms will be resting on an over-bed
table. This position helps to spread out the spaces between the ribs, where the needle is
inserted. If you are not able to sit, you may lie on your side on the edge of the bed.
- The skin where the needle will be put in will be cleaned with an antiseptic solution.
- A numbing medicine (local anesthetic) will be injected in the area.
- When the area is numb, the healthcare provider will put a needle between the ribs in your
back. You may feel some pressure where the needle goes in. Fluid will slowly be
withdrawn into the needle.
- You will be asked to hold still, breathe out deeply, or hold your breath at certain times
during the procedure.
- If there is a large amount of fluid, tubing may be attached to the needle. This will let the
fluid drain more. The fluid will drain into a bottle or bag. In some cases, a flexible tube
(catheter) will be put in place of the needle and the tubing will be attached for a day or two.
You will stay in the hospital until the catheter is removed.
- When enough fluid has been removed, the needle will be taken out. A bandage or dressing
will be put on the area.
- Fluid samples may be sent to a lab.
- You may have a chest X-ray taken right after the procedure. This is to make sure your lungs
are OK.
 Paracentesis
A paracentesis is a procedure that uses a hollow needle or plastic tube (catheter) to remove fluid
from the abdominal cavity. A paracentesis may also be called an abdominal tap. A paracentesis is
done when a person has a swollen abdomen, pain or problems breathing because there is too much
fluid in the abdomen (ascites). Normally, there is little or no fluid in the abdomen. Removing the
fluid helps relieve these symptoms. The fluid may be examined to help find out what is causing
the ascites.
How a paracentesis is done
- A paracentesis is done in an outpatient clinic or in a hospital. Depending on the amount of
fluid that needs to be removed, a paracentesis can take up to 45 minutes.
- You will lie on your back on a bed that has the head slightly raised. You won’t have
anything covering your abdomen. A local anesthetic is used to numb the area where the
doctor will put in the hollow needle.
- The doctor will use a thin, hollow needle or a catheter. The needle or catheter is pushed
through the skin and muscles into the abdominal cavity. Sometimes an ultrasound is done
to help the doctor find the best place to put the needle.
- Once the needle or catheter is in place, the excess fluid is drained. When fluid stops
draining, the needle or catheter is removed. A small bandage is used to cover the area where
the needle or catheter was inserted.
- If your healthcare team thinks that fluid will build up again, they may put a permanent tube
in place. This is called a tunnelled peritoneal drainage catheter. One end of this catheter
stays inside the body, and the other end is attached to a bottle or container outside the body.
You can drain the fluid at home and won’t have to keep going back to the hospital.

References:
Lee, S. (2014). Paracentesis. Canadian Cancer Society. https://cancer.ca/en/treatments/tests-and-

procedures/paracentesis

Thoracentesis. (n.d.). Www.hopkinsmedicine.org.

https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/thoracentesis