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STATEMENT OF THE
PROBLEM
SUBJECTIVE:
Stated: Nahihirapan
akog huminga at
saka kinakapos ako
sa paghinga.
OBJECTIVE:
Dyspnea
Observed physical
discomfort
AFE:17Y/O
DX:PLEURAL EFFUSION
NURSING
DIAGNOSIS
BACKROUND OF THE
STUDY
INEFFECTIVE
BREATHING
PATTERN
RELATED TO
TRACHEOBRONCHIAL
OBSTRUCTION
SECONDARY TO
PLEURAL
EFFUSION AS
EVIDENCED BY
DYSPNEA
Tracheobronchial
obstruction
use of accessory
muscle noted
mucus/secretion
Impaired cardiac
filling/inflamed pleural
membranes
(intensified on inspiration)
production
Dyspnea, difficulty in
Gamotin
Trixie 1
GOAL
LONG TERM
OUTCOME:
INTERVENTION
RATIONALE
INDEPENDENT:
Assess respiratory
rate and depth by
listening to lung sounds.
Establish a
normal/effective
respiratory pattern
AEB absence of s/s of
hypoxia, normal skin
color.
these signify an
increase in work of
breathing
SHORT TERM
OUTCOME:
After 2 days of
nursing intervention,
the client will be able
to:
After 4 hours of
nursing intervention,
the client will be able
to:
verbalize awareness
of causative factors
demonstrate
this provides
adequate oxygenation
to prevent patient from
desaturation
EVALUATION
LONG TERM
OUTCOME
ACHIEVED:
After 2 days of
nursing intervention,
the client will be able
to:
Establish a
normal/effective
respiratory pattern
AEB absence of s/s of
hypoxia, normal skin
color.
SHORT TERM
OUTCOME
ACHIEVED:
After 4 hours of
nursing intervention,
the client will be able
to:
verbalize awareness
of causative factors
PATIENT:X
AFE:17Y/O
DX:PLEURAL EFFUSION
breathing, altered chest
appropriate coping
excursion, respiratory
behaviors like proper
depth changes
breathing and
coughing
Reference: Medical
Surgical Nursing:Brunner
11th edition, p.652
activities providing
adequate rest periods
Encourage sustained
deep breaths by
emphasizing slow
inhalation, holding end
inspiration)
This prevents
dyspnea resulting
from fatigue
these promote deep
inspiration
Teach client
appropriate deep
breathing and coughing
techniques
COLLABORATIVE:
Administer oxygen at
lowest concentration
indicated
Gamotin
Trixie 2
these facilitate
adequate clearance of
secretions
For management of
underlying pulmonary
condition and
respiratory distress.
--.for proper
counseling and intake
of caloric needs.
demonstrate
appropriate coping
behaviors like proper
breathing and
coughing
PATIENT:X
Gamotin
Trixie 3
AFE:17Y/O
DX:PLEURAL EFFUSION