WOC

Invasion of pilogenic bacilli into pleura Infection from the Lungs Infection from outside lungs Perietal-visceral pleural
vibrous attachment
CATEGORY
Acute Inflammation
Thoracocentasis Antibiotic
DS :
administration Fibrothorax
Hyperther PMN Increased Serous Exudate Increased Protein Levels
Pleurodesis Bed rest
mia
Biopsi dan aspirasi pleura Mechanical drag
(D0130)
Drainage/ Cloudy and thick fluid (Pus) in the pleural cavum
Fever occurs Invasive Friction on pleura during breathing
procedure Emphyema
Elevated body temperature Pleuritis pain
DS : Infection Increased intrapleural pressure
Histamine and pyrogenic substances Risk (D0143) DS : Acute Pain
Pleural Effusion (D0077)
Fluid collection in the pleural cavity
Inflammatory
response
Increased intrapleural pressure Limited lung expansion
Increased capillary permeability

Pulmonary collapse Impaired lung

Purulent exudate on bronchi
Decreased lung surface area Disturbed ventilation
Increased secretion production Irritation/ulceration of bronchi
Lactic acid increases Hypoxia PO2 decreased, PCO2 increased Hypercapnic
Productive cough Hemoptysis
Decreased blood pH Kusmaul Dyspnea/ Asidosis respiratoric
breathing breathlessn
DS: Airway clearance ineffectiveness (D0001)
Asidosis metabolic
DS : Activity DS : Ineffective breath pattern
intolerance (D0056) (D0005)
Ineffective airway clearance (D.0001) Airway
Management (I. 01011)
Observation
1) Monitor breath patterns (frequency,
depth, breath effort)
2) Monitor for additional breath sounds
3) Monitor sputum
Therapeutic
1) Maintain airway patency with head-tilt
and chin-lift (jaw thrust if cervical trauma
is suspected)
2) Position semi fowler or fowler
3) Perform chest physiotherapy, if necessary
4) Perform lung suction for less than 15
seconds
5) Give oxygen, if necessary
Education
1) Teach fluid intake 2000 ml/day, if not
contraindicated
2) Teach effective coughing techniques
Collaboration
1) Collaborative administration of
bronchodilators, expectorants,
mucolytics, if necessary
Hyperthermia (D.0130)
Hyperthermia management (I.15506)
Observation
1) Identify the cause of hyperthermia (e.g.
dehydration exposed to hot environment
incubator use)
2) Monitor body temperature
3) Monitor electrolyte levels
4) Monitor urine output
Therapeutic
1) Provide a cool environment
2) Loosen or remove clothing
3) Wet and fan the body surface
4) Give oral fluids
5) Change linen daily or more frequently if
experiencing hyperhidrosis (excessive
sweating)
6) Apply external cooling (e.g. hypothermic
blanket or cold compresses on forehead,
neck, chest, abdomen, axilla)
7) Avoid giving antipyretics or aspirin
8) Limit oxygen, if necessary
Education
1) Encourage bed rest
Collaboration
1) Collaborate intravenous fluids and
electrolytes, if necessary
Ineffective breathing pattern (D.0005)
Respiration monitoring (I.01014)
Observation
1) Monitor breath frequency, rhythm,
depth, and effort
2) Monitor breathing pattern (such as
bradypnea, tachypnea, hyperventilation,
Kussmaul, Cheyne Stokes, Biot, ataxic0
3) Monitor the ability to cough effectively
4) Monitor for sputum production
5) Monitor for airway obstruction
6) Palpate for symmetry of lung expansion
7) Auscultate breath sounds
8) Monitor oxygen saturation
9) Monitor AGD value
10) Monitor thoracic x-ray results
Therapeutic
1) Set the respiration monitoring time
interval according to the patient's
condition.
2) Document the monitoring results
Education
1) Explain the purpose and procedure of
monitoring
2) Inform the results of monitoring, if
necessary
Acute Pain (D.0077) Risk of Infection (D.0143)
Pain Management (I. 08238) Infection Prevention (I.14539)
Observation Observation
1) Monitor the success of the coping therapy that has been 1) Monitor signs and symptoms of local and schizemic infection
given Therapeutic
2) Monitor side effects of analgesic use 1) Limit the number of visitors
Therapeutic 2) Provide skin care to areas of edema
1) Control the environment that exacerbates pain (room 3) Wash hands before and after contact with the patient and the patient's
temperature, lighting, noise) environment
2) Facilitate rest and sleep 4) Maintain aseptic technique in high-risk patients
3) Consider the type and source of pain in choosing pain relief Education
strategies 4) 1) Explain the signs and symptoms of infection
Education 2) Encourage increased nutritional intake
1) Encourage appropriate use of analgesics 3) Encourage increased fluid intake
2) Teach non-pharmacological techniques to reduce pain 2) Collaboration
Collaboration 1) Immunization collaboration, if necessary
1) Collaboration on analgesic administration