Patient B is a 67 years old male and has been diagnosed with Pneumothorax secondary to Vehicular

Accident. With CTT connected to water seal drainage.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective After 8 hours Independent
Data: Ineffective of shift: Intervention: >Changes may Goal met:
“Nahihirapan breathing 1. Monitor rate, indicate onset The patient’s
ako huminga… pattern related Goal: rhythm, and depth of pulmonary respiratory rate
Tumusok kasi to airway The patient of respiration. Note complications. is increased
yung sarili kong obstruction will be able breathing (RR: 18 bpm)
buto sa baga ko, secondary to to establish a irregularities, for
>Ability to The patient is
kaya eto inaalis Pneumothorax. normal, example, apneustic, mobilize or able to
nila yung effective ataxic, or cluster clear demonstrate
namuong dugo respiratory breathing. secretions is breathing
sa baga ko” pattern as 2. Note competence important to exercises.
As manifested evidenced by of gag and swallow
airway
by the patient. increase reflexes and maintenance. And the patient
respiratory client’s ability to Loss of is able to
Objective rate. The protect own swallow or verbalize his
Data: patient will airway. cough reflex understanding of
With chest verbalize the
may indicate smoking free
thoracostomy understanding
3. Elevate head of need for lifestyle.
connected to of smoking
artificial
water seal free lifestyle. bed as permitted
and position on airway or
chamber at
Objective: sides, as indicated. intubation.
Right,
Bradypnea The patient
> Facilitates
will be able 4. Encourage deep
breathing if client lung expansion
Temp: 36.7’C to
and
RR: 14 bpm demonstrate is conscious
5. Auscultate breath ventilation,
BP: 130/90 breathing
sounds, noting and reduces
mm/Hg exercises to
risk of airway
PR: 79 cpm promote lung areas of
hypoventilation and obstruction by
expansion.
presence of tongue.
adventitious > Prevents or
sounds. reduces
atelectasis.
6. Monitor use of
respiratory >Identifies
depressant drugs, pulmonary
such as sedatives. problems such
7. Instruct the as atelectasis,
patient to avoid congestion,
over-eating and gas and airway
forming foods. obstruction,
8. Maintain calm which may
attitude while jeopardize
dealing with the cerebral
patient oxygenation.
>Can increase
Dependent respiratory
Intervention: embarrassment
Administer pain and
killer/sedative/anti- complications.
pyretic as
prescribed by the >To avoid
doctor. abdominal
distension
Collaborative
intervention: >To limit
Assist in level of
Reclogging of the anxiety
CTT
Assist the patient in
>To Follow
developing plan of
patient’s
smoking cessation
therapeutic
(Inform the patient
regimen to
about the adverse
stabilize her
and side effects of
wellness of
smoking.
health.

>To promote
maximum
inspiration.
>To promote
faster healing
and to promote
patient’s
optimal health.