NURSING CARE PLAN

GENERAL OBJECTIVE
To facilitate the maintenance of oxygen
supply to all body cells

SUBJECTIVE CUES
As verbalized by the client:
Hindi ko mayo kaginhawa.
Nabudlayan ko maginhawa.

OBJECTIVE CUES

Use of accessory muscles noted

Fatigability noted
Rapid, shallow breathing noted
Respiratory rate of 38-50 cpm noted
With O2 @ @L/min via nasal cannula
IVF PNSS 1L @ 80cc/hr
With pulse oximeter
With CTT drainage at mid-axillary line

OTHERS
CXR: collapsed R. lung with marked
pneumothorax, multiple small bullae in the
collapsed R. lung, suggest apico-lordotic view.
(August 3, 2015)
ABG RESULTS:
-pCO2: 27.3
(35-45mmHg)
-pO2: 75
(80-100 L)
-HCO2: 16.3
(22-26 L)
-BE: -7.2
(-2-2 L)

OTHERS
Hematology lab results:
-Hct: 0.32
(0.37-0.47 L)
-WBC: 13
(5-10x10^9/L)
-Segmenters: 82 (50-70%)
-Lymphocyte: 11 (25-40%)

NURSING
DIAGNOSIS

RATIONALE

SPECIFIC OBJECTIVES

Impaired
breathing
pattern related
to decrease
lung
expansion 2o
to
pneumothorax

Pneumothorax occurs when

the parietal or visceral pleura
is breached and the pleural
space is exposed to positive
atmospheric pressure. Air
enters the pleural space
through a breach of the
parietal or visceral pleura.
Accumulation of air in the
pleural space causes positive
pressure, thus decreasing lung
expansion because normally
the pressure in the pleural
space is negative or
subatmospheric; this negative
pressure is required to
maintain lung inflation. Due to
decrease lung expansion the
ability to breath is impaired,
thus
increasing respiratory rate.

Within 28 hours of rendering

nursing care, the client will
be able to:

Breathe without using

accessory muscles.
Demonstrate proper
breathing exercises

NURSING INTERVENTIONS

RATIONALE

Independent:
-Monitor V/S

- Position client to semi-fowlers for

optimal breathing pattern.

- Instruct and/or change clients

position (turn every 2hrs).

- Pace activities
Maintain planned rest periods.

-Assess respirations; note quality,

rate, pattern, depth, flaring of
nostrils, dyspnea

- Have a baseline of data.

- To promote better lung expansion

and improved air exchange.

- To facilitate secretion movement

and drainage.

- To prevent fatigue.

- Abnormality indicates respiratory

compromise

-Promote energy conservation

techniques

-To prevent fatigue

NURSING INTERVENTIONS

RATIONALE

Independent:
-Demonstrate proper and teacher
proper breathing exercises.

- Teach client and SO about

environmental factors that can
precipitate respiratory problems.

- To enhance respiration

- To limit impact on client's breathing.

Collaborative:
- Provide O2

- Administer medications as ordered,

noting effectiveness and side effects.

- CTT insertion

- To increase oxygenation

- To prevent further complications

- To drain excess air or fluid from the

interstitial space.

- Monitor laboratory resuts

- To take note of any abnormalities

EVALUATION
Goal is partially met.

After 28 hours of rendering effective nursing care, the client was able to:
Demonstrate proper breathing exercises.
The clients respiratory rate decreased from 38 cpm to 30 cpm.