Divine Word College of Legazpi

College Department

Legazpi City

Bryan Pameniano Buendia

BSN 3

NCM 022 Care Of Clients W/Prob In Oxy, Fluid & Electro, Infe, Inflam & Immuno, Resp, Cell, Aberr, Acute & Chronic

Block A

1. Epistaxis

Epistaxis, or a nosebleed, is the common event of blood draining from the nose. Most people have at least one nosebleed during their lifetime. They are twice as common
in children compared with adults. Most stop with direct pressure on the nose, but some may need medical car

Classification:

 Anterior Epistaxis
 Posterior Epistaxis

Causes:

A break in blood vessels in the nose such as from an injury (blow to the nose) causes a nosebleed. Other causes include chemicals, infections, abnormal blood vessels in
the nose, and diseases such as high blood pressure or bleeding disorders. The most common cause is dry nasal passages from dry air, especially in winter.
Clinical Manifestations:

 Symptoms include bleeding from one or both nostrils and bleeding down the back of the throat with spitting, coughing, or vomiting of blood.
 Prolonged or recurrent nosebleeds may cause anemia.
 After a big nosebleed, dark or tarry bowel movements mean that a large amount of blood was swallowed.

Nursing Care Plan

Nursing care plans are a vital part of the nursing process. They give an incorporated document of the patient's condition of epistaxis, diagnosis, and the nursing team's
goals for that patient, and proportion of the patient's progress. Nursing care plans are organized to capture all the significant data for the nursing team in one spot. Since
they incorporate this data and updates, they guarantee that everything significant is archived and accessible to all colleagues.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Risk for imbalanced After 10 minutes of Dependent: "Goal met"
fluid volume related to nursing interventions,
"I am struggling with 1). Administer 1). Biogesic is a pain After 10 minutes of
active fluid loss the client will manifest
severe headache" as Biogesic as ordered reliever which help nursing interventions,
secondary to epistaxis absence of nose
verbalized by the by the physician promote comfort of the the client manifested
bleeding
patient patient absence of nose
Independent:
bleeding
• Fatigue 2). This discourages
2). Assist the patient
further bleeding. Sitting
to sit upright and lean
forward will help the
forward
Objective Data: patient avoid
swallowing blood which
• Pain scale: 8
can irritate his stomach
3). Pinch the soft,
• BP: 140/80
cartilaginous of the 3). Pinching sends
• Paleness patient's nose pressure to the
bleeding point of the
• Epistaxis
nasal septum and often
stops the flow of blood

4). Apply cold 4). Applying ice packs

compress to the help constrict blood
forehead and the vessels (which will
bridge of the patient's slow the bleeding) and
nose promotes comfort

5). Monitor the 5). To note significant

patient's vital signs changes in the
after 30 minutes patient's vital signs

6). Instruct the patient 6). Hot and spicy foods

to avoid hot and spicy could dilate blood
foods vessels in the nose
which can allow it to
bleed

7). Instruct the patient

7). Plenty of fluids
to drink plenty of fluids
rehydrate the patient
from the fluid loss of
his body
8). Teach ways to
prevent epistaxis 8). Incessant and
forceful nose blowing,
 (straining, high or sneezing can exert a
attitude avoiding great deal of trauma on
forceful nose blowing, the sensitive lining of
and nasal trauma) the inner nose and
trigger a nosebleed

9). A dry environment

9). Provide
can irritate and dry out
humidification to avoid
nasal membranes. This
drying of the nasal
can cause crusts that
passages
may itch and bleed
when picked or
scratched.

2. Acute Respiratory Distress Syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition. It is a form of breathing failure that can occur in very ill or severely injured people.

Causes:

 Chest trauma, such as a heavy blow

 Breathing vomit
 Breathing smoke, chemicals, or salt water
 Burns
Clinical Manifestations:
 Shortness of breath
 Fast, labored breathing
 Bluish skin or fingernail color
 Rapid pulse
Nursing Care Plan
ARDS has impacts beyond the lung. Delayed mechanical ventilation frequently prompts bedsores, deep venous apoplexy, failure of multi-organ system, weight reduction,
and unfortunate in general working. It is vital to have a coordinated way to deal with ARDS management since it commonly affect numerous organs in the body.
Assessment
Subjective Data:
"Hirap ako sa
paghinga, inuubo, at
nanghihina" as stated
by the patient
Objective Data:
• Shortness of breath
• Restlessness
Nursing Diagnosis Planning Intervention Rationale Evaluation
Ineffective breathing After 8 - 24 hours of 1). Assess the rate, 1). Change in rate After the several
pattern related to nursing shift, the client rhythm, and depth of and depth of hours of nursing
decreased lung will able to: respiration. respiration is the shift;
compliance and early sign of
• demonstrate normal • The patient takes
increased breathing respiratory difficulty.
breathing pattern; rate relaxed breathing at
rate possibly evidence In the case of
and depth a normal rate and
by shortness of breath, pulmonary edema
depth. There is the
excessive cough, • display absence of and other pulmonary
absence of dyspnea
tachypnea, dyspnea, dyspnea and excessive conditions, gas
and blood gas
restlessness, and coughing exchange in the
analysis shows
changes in depth of lungs is impaired,
• manifest normal rate normal parameters.
respiration which leads to
in blood gas analysis
hypoxemia as a • The patient
• Constant coughing result rate and depth verbalizes his/her
of respiration comfort without any
• Nail clubbing
increase. sign of dyspnea.
Bilateral opacity in 2). Check for the use
2). When lung • Display a
chest x-ray of accessory muscles.
compliance decreased in level of
V/S taken as follow, decreases, it excessive coughing
impacts the work of
• PR - 110 bpm • The patient
breathing and it
maintains adequate
• RR - 26 bpm increases
gas exchange as
significantly. In this
• BP - 130/90 evidenced by normal
case, the air in and
ABG findings
out in the lungs
becomes more
difficult. Lungs could
not meet the oxygen
demand of the body.
Breathing patterns
alter in this stage to
provide adequate
oxygen to the body.

3). Assess the breath 3). An increase in

sound of the lungs. pulmonary edema
cause fluid to move
into alveoli, as a
 result, a crackles
sound is heard.

4). Dyspnea causes

4). Check for any sign
an increase in
of dyspnea.
anxiety in the
patient. Anxiety
leads to increase
oxygen demand of
the body and
breathing pattern is
altered.

5). Assess for any sign 5). Bluish

of cyanosis. discolourisation of
the tongue, mucus
membrane and skin
indicates a decrease
in oxygen
concentration in the
blood. It also
indicates that the
current breathing
pattern is not
effective to meet the
oxygen demand.
6). Check oxygen 6). Pulse oxymetry
concentration in pulse and ABG analysis
oximeter and do an help to interpret the
arterial blood gas current oxygen
analysis. status in the blood.
In ARDS, oxygen
saturation
decreases. Oxygen
saturation of the
body should be kept
at 90% or higher.
ABG also indicates
respiratory acidosis
or alkalosis or
hypoxemia.

7). An increase in
7). Assess for any pulmonary edema
cough. and fibrin build up
stimulate cough
reflex and it leads to
an increase in
cough.

8). As the rate and

8). Check for the
depth of breathing
energy level of the
patient. increases, it
involves accessory
muscles and the
work of breathing
increases.
Increased work of
lungs increases
energy expenditure
and also increase
oxygen demand.

9). A decrease in
9). Assess the
oxygen
patient's level of
concentration in the
consciousness
blood leads to
alteration in brain
function. There may
be an increase in
restlessness,
confusion and
irritability.
10). Reassure the
10). The presence
patient and reduce the
of relatives or any
anxiety during acute
trusted person may
episodes of respiratory
help the patient feel
distress. less fear and can
reduce anxiety as
well as reduce
oxygen demand.

11). Provide proper 11). Check oxygen

position to the client. A saturation through
prone position is pulse oxymetry after
recommended. a change in position.
If saturation drops
down reposition the
patient as previous.
Prone position
improves oxygen
saturation in ARDS
patients who are
receiving
mechanical
ventilation. It has
been found that the
prone position
redistributes
ventilation from
ventral to dorsal
regions and
mobilizes
 secretions.

12). Schedule daily 12). Continuous

activities in such a way activity leads to
that it will provide rest fatigue. As a result,
periods between it increases the work
activities. of breathing and the
body demands more
oxygen. Rest helps
to mobilize energy
for more effective
breathing and
coughing.

13). Maintain oxygen 13). Oxygen

saturation at 90% or saturation reading

above. below 90% may be

due to hypoxia. It
may also cause
anaerobic cellular
metabolism,
alteration in
consciousness,
electrolyte
imbalance and
ultimate death.
14). Administer 14). Antibiotics help
medications according to treat underlying
to the physician’s microorganisms.
prescriptions. (e.g., Bronchodilators
antibiotics, decrease laboured
bronchodilators, breathing and do
steroids, and airway clearance.
antianxiety Anti-anxiety drugs
medications). decrease the
anxiety of the
patient.
15). Do suction if
15). Suctioning
required.
clears secretion and
gives a clear way for
breathing.
16). All the team
members who are 16). ARDS requires
involved in the care of the involvement of a
the patient must be multidisciplinary
informed about the team. Nurses
patients respiratory observe patients all
status. the time, so any
changes in
respiration are first
 observed by nursing
personnel. The
nurse must inform
all the team
members
immediately about
any change for
aggressive
intervention.

17). Anticipate any 17). When the

need for intubation or patient could not
mechanical ventilation. cope up with the
medication and
other intervention,
intubation and
mechanical
ventilation is
recommended.
Mechanical
ventilation provides
adequate oxygen to
the body.
3. Bronchitis

Bronchitis is an inflammation of the airways leading into your lungs. When your airways (trachea and bronchi) get irritated, they swell up and fill with mucus, causing you to
cough. Your cough can last days to a couple of weeks. It’s the main symptom of bronchitis.

Classification:

 Acute Bronchitis
 Chronic Bronchitis

Clinical Manifestations:

A persistent cough that lasts one to three weeks is the main symptom of bronchitis. A patient usually brings up mucus upon coughing with bronchitis, but you might get a
dry cough instead. A patient might also hear a whistling or rattling sound upon breathing (wheezing).

Patient might have other symptoms, including:

 Shortness of breath (dyspnea).

 Fever.
 Runny nose.
 Tiredness (fatigue).

Nursing Care Plan

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective airway Short-term goals: Independent: Short-term:

clearance related to
"I'm having trouble in After 8 hours of nursing 1). Assess respiratory 1). Useful in After 8 hours of nursing
excessive, thickened
breathing and interventions the rate, depth. Note use of evaluating the interventions, the client
struggling with constant mucous secretions patient will: accessory muscles, degree or was able to:
irritating cough" as pursed lip breathing, respiratory distress
•Demonstrate improved • Demonstrate improve
verbalized by the client inability to speak. and chronicity of the
ventilation and ventilation and enough
disease process.
adequate oxygen. oxygen as evidenced by
2). Oxygen delivery a normal breathe sound
Objective Data: • Arterial blood gases 2). Elevate head of the
may be improved by and normal rate of O2
(ABGs) within normal bed, assist patient
• Presence of rhonchi upright position and sat.
range. assume position to ease
breathing exercises
• Ineffective coughing work of breathing. • Maintain normal range
• No signs of to decrease airway
Encourage deep slow or of ABG
V/S taken as follows: respiratory distress. collapse, dyspnea
pursed lip breathing as
and work of • Manifest no sign of
T - 36.9 individually tolerated or
breathing. respiratory distress
indicated
P - 85 Long term:
3). Cyanosis may
3. Routinely monitor
After 4-5 weeks of be peripheral in nail
R - 26 skin and mucous Long-term
nursing interventions, beds or central in
membrane color.
BP - 110/80 lips or ear lobes.
the patient: After 4 weeks of nursing
Duskiness and interventions the patient
• Ventilation or central cyanosis was now able to:
oxygenation is enough indicate advanced
to meet self-care needs hypoxemia • Maintain effective
ventilation and
4). Encourage 4). Thick, tenacious, oxygenation in meeting
expectoration of copious secretions self-care needs.
sputum; suction when are major source if
ineffective airways.
indicated Deep suctioning
may be required
when cough is
ineffective for
expectoration of
secretions

5). Evaluate level of

5). During severe or
activity tolerance.
acute respiratory
Provide calm and quiet
distress, patient
environment
may be totally
unable to perform
basic self-care
activities because of
hypoxemia and
dyspnea
6). Evaluate sleep
6). Multiple external
patterns, note report of
stimuli and
difficulties and whether
presence of
patient feels well rested.
dyspnea may
prevent relaxation
and inhibit sleep.

7) Tachycardia,
7). Monitor vital signs
dysrhythmias, and
and cardiac rhythm
changes in blood
 pressure can reflect
effect of systemic
hypoxemia on
Collaborative: cardiac function

8).Administer 8). May correct or

supplemental oxygen as prevent worsening
indicated by ABG of hypoxia
results and patients
tolerance

4. Chronic Obstructive Pulmonary Disease (COPD)

Any respiratory disease that persistently obstructs bronchial airflow fall under the broad classification of COPD, also known as chronic airflow limitations (CAL). Chronic
Obstructive Pulmonary Disease (COPD) is a condition of chronic dyspnea with expiratory airflow limitation that does not significantly fluctuate. Within that broad category,
the primary cause of the obstruction may vary; examples include airway inflammation, mucous plugging, narrowed airway lumina, or airway destruction.

Classification:

 Asthma
 Chronic Bronchitis
 Emphysema
Causes:

 Smoking depresses the activity of scavenger cells and affects the respiratory tract’s ciliary cleansing mechanism.
 Occupational exposure. Prolonged and intense exposure to occupational dust and chemicals, indoor air pollution, and outdoor air pollution all contribute to the
development of COPD.
 Genetic abnormalities. The well-documented genetic risk factor is a deficiency of alpha1- antitrypsin, an enzyme inhibitor that protects the lung parenchyma from
injury.

Clinical Manifestations:

The natural history of COPD is variable but is a generally progressive disease.

 Chronic cough
 Sputum production
 Dyspnea on exertion
 Dyspnea at rest
 Weight loss
 Barrel chest

Nursing Care Plan

Most patients with COPD receive outpatient treatment, the nurse should develop a teaching plan to help them comply with the therapy and understand the nature of this
chronic disease.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective airway Short-term goal: 1). Establish Rapport 1). To gain patient’s Short-term
clearance related to trust. goal:(achieved)
"Hirap ako sa pag-ubo After 5-8 hours of
at nahihirapan akong bronchospasm, nursing interventions 2). This information is After 8 hours of
huminga" as verbalized increased production the client will be able essential for identifying nursing interventions
2). Assess level of
by the patient of tenacious to: potential for airway the client was able to:
consciousness/cognition
secretions as problems, providing
Objective: • Maintain airway and ability to protect • Maintain airway
evidenced by baseline level of care
patency, clear breath own airway. patency and manifest
• Tachypnea presence of wheezes needed, and
sounds upon clear breathe sounds
influencing choice of
• Nasal flaring auscultation
interventions. • Expectorate
• Pale lips and oral • Expectorate/clear secretions readily
3). Indicative of
mucous membrane secretions readily 3). Monitor respirations
respiratory distress
and breath sounds,
• Use of accessory and/or accumulation of
noting rate and sounds Long-term goals:
muscle when breathing secretions.
Long-term goals: (e.g., tachypnea, stridor, (achieved))
• Cyanosis crackles, or wheezes)
After 2-3 weeks of • After 2 weeks of
indicative of respiratory
• With productive nursing interventions nursing interventions
distress and/or
cough of thick, the client will be able the client was now
accumulation of
gelatinous sputum to: able to:
secretions.
4) To determine ability
• Stocky build • Manifest stable vital • Maintain stable vital
4). Evaluate client’s to protect own airway
signs signs as evidence by
• Wheezes upon cough/gag reflex,
absence of abnormal
auscultation on both • Get rid of tenacious amount and type of
RR, PR, T, BP rate.
lungs during inspiration secretions secretions, and
swallowing ability • Manifest the full
• Capillary refill < 3 • Verbalize 5). To clear airway
absence of tenacious
understanding of 5). Suction nose, mouth, when excessive or
seconds cause(s) and and trachea PRN viscous secretions are secretions
therapeutic blocking airway or
• Demonstrate
management regimen client is unable to
reduction of
swallow or cough
• Demonstrate congestions as
effectively.
absence/reduction of evidenced by clear
congestion with breath 6). To take advantage breath sound upon
6). Elevate head of bed,
sounding clear and of gravity decreasing auscultation and has
encourage early
improved oxygen pressure on the improved oxygen
ambulation, or change
exchange (absence of diaphragm and exchanged as
client’s position every 2
cyanosis enhancing drainage evidenced by
hr.
of/ventilation to absence of cyanotic
different lung appearance.
segments.
7). Teach about pursed-
lip breathing and 7). Pursed-lip breathing

diaphragmatic breathing is used for dyspneic

episodes to encourage
the patient to breath
out longer that will
increase the patient’s
oxygen levels.
Diaphragmatic
breathing uses
abdominal muscles
rather than accessory
 muscles which helps to
strengthen the
diaphragm, slows down
the breathing rate.

8). Encourage deep- 8. Induced coughing

breathing and coughing and deep breathing
exercises. helps improve clearing
secretions and
increases oxygenation.

9). Administer
9). To relax smooth
medications (e.g.,
respiratory
expectorants, anti-
musculature, reduce
inflammatory agents,
airway edema, and
bronchodilators, and
mobilize secretions.
mucolytic agents), as
indicated

10). Increase fluid 10). Hydration can help

intake to at least 2,000 prevent the
mL/day within cardiac accumulation of
tolerance (may require viscous secretions and
IV in acutely ill, improve secretion
hospitalized client). clearance. Monitor for
signs/symptoms of
congestive heart failure
 (crackles, edema, or
weight gain) when the
client is at risk.
11). Perform or assist
11). Various
the client in learning
therapies/modalities
airway clearance
may be required to
techniques, such as
acquire and maintain
postural drainage and
adequate airways and
percussion (chest
improve respiratory
physical therapy [CPT]
function and gas
exchange

12). Educate about the 12). Information about

disease process and the disease and its
lifestyle modifications possible outcomes
regarding COPD. might improve
Support compliance with the
reduction/cessation of treatment plan
smoking.
5. Asthma

Asthma is a chronic inflammatory lung disease that causes airway hyper responsiveness, mucus production, and mucosal edema resulting in reversible airflow obstruction.

Causes:

Allergens, air pollutants, cold weather, physical exertion, strong odors, and medications are common predisposing factors for asthma. When an individual is exposed to a
trigger, an immediate inflammatory response with bronchospasm happens.

Clinical Manifestation:

 Constant irritating cough

 Dyspnea
 Wheezing
 Increased mucus production

Nursing Care Plan

The nursing care plan objectives for asthma centers around preventing the hypersensitivity response, controlling the allergens, keeping up with airway patency, and
forestalling the event of reversible complications.

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Activity intolerance Child will engage in 1). Assess the 1). Provides information After the nursing shift,
related to fatigue and normal activities with presence of weakness about energy reserves the patient has no
• A 10 year old
airway problem as absence of fatigue and and fatigue caused by as dyspnea and work of longer struggling from
patient has reported
evidence by tired airway problem airway problem. breathing over a period a constant fatigue and
constant fatigue and
appearance, lethargy, of time wears out these was able to perform
difficulty of breathing
prolonged dyspnea due activities free from
• "Nahihirapan pong to an asthma attack, and 2). Encourage activities reserves. irritating cough
huminga ang anak ko inability to speak, eat, such as quiet play,
2). Avoids change in
at madali syang play reading, watching
respiratory status and
mapagod kahit sa movies, games during
energy depletion due to
mga simpleng rest.
excessive activity.
paglalaro lang”.
3). Disturb only when
3). Conserves energy
• (+) hx of asthma necessary, perform all
and limits interruption in
care at one time
rest.
instead of spreading
Objective: over a long period of
time, avoid doing any
Data:
care or procedures

• Abnormal wheezing during an attack.

breath sound
4). Schedule and 4). Promotes adequate
• Dyspnea provide rest periods in rest and decreases
a calm peaceful stimuli.
• restlessness environment.
5). Promotes
• constant coughing 5). Explain the reason understanding of the
for the need to
• presence of sticky effect of activity on
conserve energy and breathing and the need
mucus
avoid fatigue to parents for rest to prevent
and child. fatigue.

VS taken as follows: 6). Assist in planning a 6). Provides care while

 T - 37. 4 schedule for bathing, promoting activities of
feeding, rest that will daily care.
P - 115 bpm
save energy and
R - 33 bpm prevent an attack or
promote resolution of
BP - 110/80 mmhg
an attack.
7). Provides preventive
7). Reinforce activity or measures to offset
exercise limitations if possible attack.
these trigger attack;
advise physician
approved activities
(aerobics, walking,
swimming).

6. Pneumothorax

Pneumothorax, or a collapsed lung, is the collection of air in the spaces around the lungs. The air buildup puts pressure on the lung(s), so it cannot expand as much as it
normally.

Classification:

 Simple Pneumothorax
 Traumatic Pneumothorax
  Tension Pneumothorax

Causes:

The cause leads to the identification of the type of pneumothorax.

 Rupture of a bleb
 Blunt trauma
 Invasive procedures
 Penetrating chest

Clinical Manifestations

The signs and symptoms associated with pneumothorax depend on its size and cause.

 Pain
 Minimal respiratory distress
 Dyspnea
 Central cyanosis
 Decreased chest expansion
 Diminished breath sound
 Tracheal alignment - in simple pneumothorax, the trachea is midline while in tension pneumothorax, the trachea is shifted away from the affected side.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Ineffective breathing • Establish a 1). Determine etiology 1). Understanding After the nursing shift,
pattern may be related normal/effective and precipitating factors the cause of lung the patient
• Patient verbalized to decreased lung respiratory pattern (spontaneous collapse, collapse is demonstrated the
pain with a score of 10 expansion (air/fluid with ABGs within trauma, malignancy, necessary for proper following:
out of 10 in pain scale accumulation), pain, patient’s normal infection, a complication chest tube
• Pain is relieved
and anxiety possibly range. of mechanical placement and
• (+) hx of
evidence by difficulty of ventilation). choice of other • Established a
pneumothorax • Report absence of
breathing, cyanosis, therapeutic normal, effective
pain
abnormal ABGs and measures. respiratory pattern as
altered chest excursion • Increase perfusion evidenced by
Objective Data: 2). Respiratory
absence of cyanosis.
• Be free of cyanosis 2). Check out distress and
• Cyanotic
and other respiratory function, changes in vital • Demonstrated
• Tachypnea signs/symptoms of noting rapid or shallow signs may occur as increase in perfusion.
hypoxia. respirations, dyspnea, a result of
• Dyspnea • Patient is relaxed
reports of “air hunger,” physiological stress
and reported anxiety
development of and pain or may
• Facial grimace
is reduced to a
cyanosis, changes in indicate the
• abnormal ABGs manageable level.
vital signs. development of
(respiratory alkalosis) shock due to • Adhered to
hypoxia or prescribed
• Irregular breathing
hemorrhage. pharmacological
regimen.
3). Observe for 3). Difficulty

synchronous respiratory breathing “with”

pattern when using a ventilator and

mechanical ventilator. increasing airway

Note changes in airway pressures suggests

pressures. worsening of
condition or
development of
complications
(spontaneous
rupture of a bleb
creating a new
pneumothorax).
4). Auscultate breath
sounds. 4). Breath sounds
may be diminished
or absent in a lobe,
lung segment, or
entire lung field
(unilateral).
Atelectatic area will
have no breath
sounds, and partially
collapsed areas
have decreased
sounds. Regularly
scheduled
evaluation also
helps determine
areas of good air
exchange and
 provides a baseline
to evaluate the
resolution of
pneumothorax

5). Note chest 5). Chest excursion

excursion and position is unequal until lung
of the trachea. re-expands. Trachea
deviates away from
the affected side
with tension
pneumothorax

6). Voice and tactile

6). Assess for fremitus. fremitus (vibration)
are reduced in fluid-
filled or consolidated
tissue.

7). Assist patient with 7). Supporting chest

splinting painful area and abdominal
when coughing, deep muscles make
breathing. coughing more
effective and less
traumatic.
8). Maintain a position
8). Promotes
of comfort, usually with
the head of bed maximal inspiration;
elevated. Turn to the enhances lung
affected side. expansion and
Encourage patient to sit ventilation in
up as much as possible. unaffected side.

9). Maintain a calm 9). Assists patient to

attitude, assisting the deal with the
patient to “take control” physiological effects
by using slower and of hypoxia, which
deeper respirations. may be manifested
as anxiety or fear.

10). Maintains
10). Once the chest
prescribed
tube is inserted:
intrapleural
negativity, which
promotes optimum
lung expansion and
fluid drainage. Note:
Dry- seal setups are
also used with an
automatic control
valve (AVC), which
provides a one-way
valve seal similar to
 that achieved with
the water-seal
system.
11). Check suction
11). Water in a
control chamber for a
sealed chamber
correct amount of
serves as a barrier
suction (determined by
that prevents
water level, wall or table
atmospheric air from
regulator at correct
entering the pleural
setting;
space should the
suction source be
disconnected and
aids in evaluating
whether the chest
drainage system is
functioning
appropriately.

12). Bubbling during

12). Observe water-seal
expiration reflects
chamber bubbling
venting of
pneumothorax
(desired action).
Bubbling usually
decreases as the
 lung expands or
may occur only
during expiration or
coughing as the
pleural space
diminishes. Absence
of bubbling may
indicate complete
lung re-expansion
(normal) or
represent
complications such
as obstruction in the
tube.
13). Observe for
13). With suction
abnormal and
applied, this
continuous water-seal
indicates a
chamber bubbling
persistent air leak
that may be from a
large pneumothorax
at the chest insertion
site (patient-
centered) or chest
drainage unit
 (system-centered).

14). Know the location 14). If bubbling

of air leak (patient- or stops when the
system-centered) by catheter is clamped
clamping thoracic at the insertion site,
catheter just distal to leak is patient-
exit from the chest. centered (at
insertion site or
within the patient).
15). Place petrolatum
15). Usually corrects
gauze and other
insertion site air
appropriate material
leak.
around the insertion as
indicated.

16). Clamp tubing in 16). Isolates location

stepwise fashion of a system-
downward toward the centered air leak.
drainage unit if air leak Note: Information
continues indicates that
clamping for a
suspected leak may
be the only time that
the chest tube
should be clamped.
17). Seal drainage 17). Prevents and
tubing connection sites corrects air leaks at
securely with connector sites.
lengthwise tape or
bands according to
established policy

18). Monitor water-seal 18). The water-seal

chamber “tidaling.” Note chamber serves as
whether the change is an intrapleural
transient or permanent manometer (gauges
intrapleural
pressure); therefore,
fluctuation (tidaling)
reflects pressure
differences between
inspiration and
expiration. Tidaling
of 2–6 cm during
inspiration is normal
and may increase
briefly during
coughing episodes.
Continuation of
excessive tidal
fluctuations may
 indicate the
existence of airway
obstruction or the
presence of a large
pneumothorax
19). Position drainage
system tubing for an 19). Improper
optimal function like position, kinking, or
shorten tubing or coil accumulation of
extra tubing on the bed, clots or fluid in the
making sure tubing is tubing changes the
not kinked or hanging desired negative
below the entrance to pressure and
drainage container. impedes air or fluid
Drain accumulated fluid evacuation. Note: If
as necessary a dependent loop in
the drainage tube
cannot be avoided,
lifting and draining it
every 15 min will
maintain adequate
drainage in the
presence of a
hemothor.

20). Assess the amount 20). Useful in

of chest tube drainage, evaluating resolution
noting whether the tube of pneumothorax
is warm and full of and development of
blood and bloody fluid hemorrhage
level in the water-seal requiring prompt
bottle is rising intervention. Note:
Some drainage
systems are
equipped with an
auto transfusion
device, which allows
for salvage of shed
blood.
21). Evaluate the need
for tube stripping 21). Although

(“milking”) routine stripping is

not recommended, it
may be necessary
occasionally to
maintain drainage in
the presence of
fresh bleeding, large
blood clots or
purulent exudate
(empyema).
22). Strip tubes 22). Stripping is
carefully per protocol, in usually
a manner that uncomfortable for
minimizes excess the patient because
negative pressure of the change in
intrathoracic
pressure, which may
induce coughing or
chest discomfort.
Vigorous stripping
can create very high
intrathoracic suction
pressure, which can
be injurious
(invagination of
tissue into catheter
eyelets, collapse of
tissues around the
catheter, and
bleeding from
rupture of small
23). If the thoracic blood vessels
catheter is
disconnected or
dislodged:
• Observe for signs of •Pneumothorax may
respiratory distress. If recur, requiring
possible, reconnect prompt intervention
thoracic catheter to to prevent fatal
tubing or suction, using pulmonary and
clean technique. If the circulatory
catheter is dislodged impairment.
from the chest, cover
insertion site
immediately with
petrolatum dressing and
apply firm pressure.
Notify physician at
once.

24). After the thoracic

catheter is removed:

• Cover insertion site • Early detection of a

with a sterile occlusive developing

dressing. Observe for complication is

signs and symptoms essential

that may indicate (recurrence of

recurrence of pneumothorax,

pneumothorax presence of

(shortness of breath, infection).

reports of pain. Inspect
insertion site, note
character of drainage).
• Monitors progress
• Review serial chest x-
of resolving
rays.
hemothorax or
pneumothorax and
re-expansion of the
lung. Can identify
malposition of the
endotracheal tube
(ET) affecting lung
re-expansion.

• Monitor and graph • Assesses status of

serial ABGs and pulse gas exchange and

oximetry. Review vital ventilation, need for

capacity and tidal continuation or

volume measurements. alterations in

therapy.

• Aids in reducing
• Administer work of breathing;
supplemental oxygen promotes relief of
via cannula, mask, or respiratory distress
mechanical ventilation and cyanosis
 as indicated. associated with
hypoxemia.

7. Pleural Effusion

Pleural effusion is the accumulation of excess fluid in the lung space, the space between the membrane lining the lungs and the membrane lining the chest wall.

Classification:

 Transudative: a state in which decreased protein leads to pressure changes in the blood vessels causing leakage of protein-poor fluid into the lung space.
 Exudative: Inflammatory process leading to leakage of protein-rich fluid into the lung space.

Causes:

Transudative:

 Heart failure
 Hepatic cirrhosis
  Malnutrition
 Nephritic syndrome

Exudative:

 Pneumonia
 Cancer
 Tuberculosis
 Autoimmune disease

Clinical Manifestations

 Sharp, stabbing pain in the chest on inspiration

 Dyspnea
 Orthopnea
 Dry, non-productive cough (fluid leakage is outside of the lung in the pleura, hence no productive cough)
 Diminished breath sounds
 Tachycardia
 Unrelated symptoms of the condition causing pleural effusion
 Possible mediastinal shift on x-ray

Nursing Care Plan

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Impaired Gas The patient will Independent: 1). To establish a After the nursing shift,
Exchange related to achieve effective baseline. Gas the client was able to
• Patient verbalized the altered supply of breathing pattern and 1). Check the exchange is affected by breathe easily and
difficulty of breathing oxygen secondary to oxygen saturation of patient’s breathing rapid and shallow manifested normal
Pleural Effusion as above 96% rate, characteristics, breathing patterns, as vital signs as
• "Sobra akong
evidenced by frequent including the well as hypoventilation. evidenced by optimal
nanghihina, sumasakit • The patient will be
coughing, difficulty of involvement of Hypoxia, on the other gas exchange, normal
ang aking dibdib sa bawat able to maintain
breathing, nasal accessory muscles hand, is characterized breathing pattern, and
paghinga at madalas ang optimal gas exchange
flaring, restlessness, when breathing, and by an increased stabilized vital signs.
aking pag-ubo" and finally achieve
use of accessory any other irregular respiratory rate, the
ease of breathing as
muscles when breathing patterns. employment of
evidence by absence
breathing, and Auscultate the lungs accessory muscles,
Objective Data: of cough and
increased cardiac and monitor for nasal flaring,
dyspnea.
• frequent coughing rate. adventitious breath diaphragm breathing,
sounds. and a panicky
• dyspnea appearance in the
patient’s eyes.
• use of accessory muscle
during respiration 2). Watch out for nail
2). Central cyanosis of
beds and skin
the tongue and oral
cyanosis, as well as
mucosa signals severe
the color of the
VS: hypoxia and requires
tongue and oral
immediate medical
• RR - 29 bpm mucous membranes.
attention, whereas
• PR - 120 bpm peripheral cyanosis of
the extremities may or
• Oxygen Sat.- 89%
may not be significant.
 3). Pulse oximetry is an
effective method for
3). Constantly
detecting oxygenation
monitor the patient’s
abnormalities.
oxygen saturation
Significant oxygenation
through a pulse
concerns are indicated
oximeter.
by an oxygen
saturation of less than
90% or a partial
pressure of oxygen of
less than 80.

4). Constantly check 4). Elevated Carbon

the results of blood dioxide levels and

chemistry and arterial diminishing levels of

blood gases (ABG). oxygen may indicate

respiratory acidosis
and hypoxemia (low
level of blood oxygen,
particularly in the
arteries).

5). Place the patient 5). Improved thoracic

in a high or semi- capacity, complete
Fowler’s position with diaphragm fall, and
the head of the bed increased lung
elevated. Also, expansion prevent
encourage the patient abdominal contents
to sit in an upright from crowding when
position if tolerated. placing the patient in
the upright or semi-
Fowler’s position.
6). Analyze the
6). Ventilation and
influence of shifting
perfusion imbalances
positions on ABGs
are aggravated by
and pulse oximetry
positioning the patient’s
readings.
most impaired lung
regions in the
dependent position,
where perfusion is
greatest.

7). Monitor the 7). The patient’s

patient’s position at a abdomen compresses

regular interval to the diaphragm and

ensure that they do inhibits adequate lung

not slump in bed. expansion while he or

she is in slumped or
slouched position.

8). Encourage the 8). Gas exchange is

patient to cough and hindered by excessive
practice deep secretions that have
breathing techniques. accumulated in the
lungs. Coughing and
deep breathing
exercises will help the
patient evacuate
secretions from his or

Dependent: her lungs.

9). Administer 9). Oxygen therapy

supplemental oxygen may be necessary to

as directed by the maintain the adequate

attending physician, oxygen level of the

aiming for an oxygen patient.

saturation level of
90% or above.
10). Humidified oxygen
10). Deliver
minimizes the risk of
humidified oxygen as
drying out the lungs of
ordered by the
the patient.
physician.
11). Anxiety makes
11). Assist the patient
signs and symptoms
in alleviating their
including shortness of
anxiety level by
breath, respiratory rate,
providing
and effort in breathing
reassurance. worse.

12). Promote or 12). Chest expansion,

assist ambulation in secretion evacuation,
patients who are and deep breathing are
ambulatory, as all improved by
recommended by the ambulation.
attending physician.
13). Thoracentesis is a
13). Prepare the slightly invasive
patient for the medical management
procedure of in which a needle is
thoracentesis. inserted through the
chest wall into the
pleural space to extract
fluid or air from around
the lungs in order to
diagnose and treat
pleural effusions.

14). Start preparing 14). Pleurectomy,

the patient for which involves

pleurectomy or surgically separating

pleurodesis the parietal and

procedure as visceral layers of the

indicated by the lungs, induces an

inflammatory response
attending physician if that leads to adhesion
pleural effusion formation between the
occurs repeatedly. two layers as they
regenerate.
Pleurodesis, on the
other hand, is a
procedure that includes
infusing a sclerosing
substance into the area
between the lung and
the chest wall to
prevent fluid or air from
accumulating between
Collaborative: the layers.

15). Refer the patient 15). To provide further

to a chest knowledge and
physiotherapist as personalized treatment
necessary. to the patient, resulting
in enhanced gas
exchange
8. Pulmonary Tuberculosis (PTB)

Pulmonary Tuberculosis (PTB) is an acute or chronic infection caused by Mycobacterium tuberculosis, tuberculosis is characterized by pulmonary infiltrates, formation of
granulomas with caseation, fibrosis, and cavitation.

Classification:

Data from the history, physical examination, TB test, chest xray, and microbiologic studies are used to classify TB into one of five classes.

 Class 0. There is no exposure or no infection.

 Class 1. There is an exposure but no evidence of infection.
 Class 2. There is latent infection but no disease.
 Class 3. There is a disease and is clinically active.
 Class 4. There is a disease but not clinically active.
 Class 5. There is a suspected disease but the diagnosis is pending.

Causes:

 Close contact w/ TB patient

 Low immunity
 Substance abuse (smoking, alcohol, IV drugs)
 Poor health access
 Immigration
 Overcrowding

Clinical Manifestations

After an incubation period of 4 to 8 weeks, TB is usually asymptomatic in primary infection.

  Nonspecific symptoms. Nonspecific symptoms may be produced such as fatigue, weakness, anorexia, weight loss, night sweats, and low-grade fever, with fever
and night sweats as the typical hallmarks of tuberculosis.
 Cough. The patient may experience cough with mucopurulent sputum.
 Hemoptysis. Occasional hemoptysis or blood on the saliva is common in TB patients.
 Chest pains. The patient may also complain of chest pain as a part of discomfort.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective Data: Ineffective airway Short-term goals: Independent: At the end of the shift, the
clearance related to client was able to display
"Sobrang nahihirapan • Within 6 hrs of 1). Assess 1). Provides a basis for
poor cough effort as patency of airways
na akong huminga at nursing interventions, respiratory rate evaluating adequacy of
evidenced by manifested by:
madalas ang aking the patient will be able ventilation
abnormal breath
panghihina" to: • secretions decreased
sounds and difficulty 2). Use of accessory
2). Noted chest
of breathing *display decreasing muscle of respiration • Client's respiratory rate
movement; use of
amount of secretions may occur in response is within normal range;
Objective Data: accessory muscle
to ineffective ventilation RR - 19bpm
*achieve normal range during respiration
• Dyspnea
of respiration 3). Crackles indicates • Client's remains calm
3). Auscultated
• Use of accessory accumulation of and manifested absence
*manifest absence of breath sounds;
muscle for respiration secretions and inability of restlessness.
restlessness opted areas with
to clear airways
• Elevates shoulders presence of
adventitious
• Abnormal breath
sounds associated Long-term goals: sounds (crackles)
with wet crackles.
• During the client's 4). Document 4). Expectorations may
• Restless stay at the hospital, he respiratory be different when
will be able to keep secretions; secretions are very thick
patent airway as character and
VS: evidence by: amount of sputum
5). Positioning helps
• BP - 82/60 hhmg *normal respiration as 5). Maintained
maximize lung
evidence by absence patient on
• T - 36.5 expansion
of dyspnea and wet moderate high back

• RR- 26 cpm crackles rest

• PR - 75 bpm *normal breathing 6). Check for 6). To maintain

pattern; RR = 12-20 obstructions; adequate airway
cpm accumulation of patency
secretions
*absence of bronchial
secretions Dependent:

*mitigate restlessness 7). Take medication

as ordered by the
physician
9. Pneumonia

Pneumonia is an inflammation of the lung parenchyma associated with alveolar edema and congestion that impair gas exchange. Pneumonia is caused by a bacterial or
viral infection spread by droplets or by contact.

Classification:

 Community-Acquired Pneumonia (CAP)

 Hospital-Acquired Pneumonia (HAP)

Other types include:

 Bronchopneumonia (bronchial pneumonia)

 Interstitial (Reticular) Pneumonia
 Aspiration Pneumonia

Causes:

Community-Acquired Pneumonia

 Streptococcus pneumonia
 Haemophilus influenza
 Mycoplasma pneumonia

Hospital-Acquired Pneumonia

 Staphylococcus aureus
 Impaired host defenses
 Comorbid conditions
 Supine positioning
  Prolonged hospitalization

Clinical Manifestations

The main symptoms of pneumonia are coughing, sputum production, pleuritic chest pain, shaking chills, rapid shallow breathing, fever, and shortness of breath. If left
untreated, pneumonia could complicate hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective data: Ineffective breathing Short-term goal: Dependent: After 30 mins of nursing
pattern related to interventions the patient
• Chills • after 30 minutes of 1). Obtain appropriate 1). Gives us a
decreased lung has verbalized less pain
nursing intervention labs (antibiotic troughs, baseline; identifies
• Dyspnea expansion and pain as
the patient will able to sputum cultures, ABGs, pathogens, and • after 8 hrs. of nursing
evidenced by changes
• Pain manifest relieve of etc.) enables us to interventions the patient
in rate, depth of
pain evaluate if manifested effective
• Altered Mental State respirations and
interventions are breathing pattern and
(AMS) reduced vital capacity • After 8 hrs of nursing
Independent: effective vital signs effectively
intervention the
recovered
patient should 2). Complete a full 2). Enables quicker

Objective data: verbalize total respiratory assessment interventions and • within week of nursing
improvement in to detect changes or may change them interventions normal
• Cough breathing pattern and (for example, breathing already
further decompensation
display increased vital as early as possible, wheezing noted on maintained and patient
• phlegm
and notify MD as auscultation would reported absence of
• Rhonchi/wheezes capacity. indicated potentially indicate labored breathing, pain
steroids and a and chills.
VS:
breathing treatment,
• 29 bpm Long-term goal: while crackles could
require suctioning,
• T - 38.9 • within 1 week of
repositioning, and
nursing interventions
• O2 Sat - 78% potential fluid
the patient will fully
restriction)
recover from pain,
dyspnea, chills 3). Normothermia
3). Promote optimizes oxygen
secondary to
normothermia (warm consumption
pneumonia, and
patient if the
manifest stabilized
hypothermic, cool
normal vital signs.
patient and administer
• the patient should antipyretics if
achieve and maintain hyperthermic)
effective breathing
4). Cluster care 4). Activity
pattern
intolerance is
• the patient should common because of
gain enough decreased gas
understanding about exchange; cluster
the present condition your care to
conserve your
patient’s energy for
essential tasks like
 ambulation,
coughing, and deep
breathing, and
eating

5). Promote airway 5). We want to

clearance encourage coughing
to remove phlegm;
do not suppress
cough unless
clinically indicated. If
the patient is able to
clear their own
airway, continue to
encourage this. If
not, suction
frequently and
consider an
advanced airway to
ensure a patent
airway, which
ultimately maximizes
gas exchange.
Getting phlegm out
is important.
6). Optimize fluid
balance 6). Patients with
pneumonia may not
be consuming
adequate oral intake
due to fatigue or not
feeling well, but
hydration is
essential to healing.
Patients may need
IV fluids if PO intake
is inadequate.
7). Assess and treat
7). If patients are not
pain
coughing because of
pain, it will only
allow fluid to
continue to build.
Treat pain
appropriately and
encourage them to
cough to clear
phlegm.

8). Coughing and

8). Encouraging
deep breathing
coughing and deep
encourages
breathing expectoration, which
enables better gas
Collaborative:
exchange
9). Promote nutrition
9). Patients with
pneumonia typically
tire easily and have
poor appetites, but
need appropriate
nutrition and
hydration to heal

10). Administer 10). Due to the

supplemental oxygen impaired gas
as appropriate exchange, oxygen
doesn’t make it into
circulation as easily.
Providing additional
oxygen supports this
as much as
possible. Use
caution in patients
with underlying lung
conditions.

11). Administer 11). Patients may be

antibiotics in a timely on antibiotics,
 fashion, draw troughs therefore it’s
appropriately essential to ensure
they are
administered at the
appropriate time and
not delayed, as this
will impair their
efficacy.

12). Educate patient 12). Patients must

and loved ones on the be aware of how

importance of energy these aspects of

conservation, effective recovery are

airway clearance, pertinent so they will

nutrition, as well as be more likely to

coughing and deep participate and

breathing remain compliant.

10. Sarcoidosis

Sarcoidosis is an inflammatory disease that affects one or more organs but most commonly affects the lungs and lymph glands. As a result of the inflammation, abnormal
lumps or nodules (called granulomas) form in one or more organs of the body. These granulomas may change the normal structure and possibly the function of the
affected organ(s).
Causes:

The cause of pulmonary sarcoidosis is unknown. Experts think that bacteria, viruses, or chemicals might trigger the disease. It may also be genetic. This means a person
is more likely to develop sarcoidosis if someone his or her close family has it. This is an active area of research.

Clinical Manifestations:

The following are the most common symptoms of pulmonary sarcoidosis. However, each person may experience symptoms differently. Symptoms may include:

 Shortness of breath, which often gets worse with activity

 Dry cough that will not go away
 Chest pain
 Wheezing

Sarcoidosis can also cause symptoms not directly related to the lungs, such as:

 Extreme tiredness
 Fever
 Inflammation of the eyes and pain, burning, blurred vision, and light sensitivity
 Night sweats
 Pain in the joints and bones
 Skin rashes, lumps, and color changes on face, arms, or shins
 Swollen lymph nodes
 Weight loss
Nursing Care Plan

Assessment Nursing Diagnosis Planning Interventions Rationale Evaluation

Subjective data: Intense pain related to Short term goal: Independent: Short-term go has met.
granulomas in the lower After 8 hrs of nursing
"Palagi nalang akong • after 8 hrs of nursing 1). Administer 1). To provide pain
legs and joints interventions the
nanghihina at interventions the patient prescribed medications relief to the patient.
secondary to patient verbalized "no
madalas mawalan ng will demonstrate relief of that alleviate the
sarcoidosis, as pain" at all.
gana sa mga pain as evidenced by a symptoms of pain.
evidenced by pain scale
gawain.. Kasabay pa pain score of 0 out of 2). To monitor • normal vital signs has
of 9 out of 10, 2). Assess the patient’s
nun, nahihirapan 10, stable vital signs, effectiveness of manifested
verbalization of strain- vital signs and
akong huminga at and absence of medical treatment for
like chest pain, characteristics of pain
sobrang sumasakit restlessness. the relief of pain. The
fretfulness, respiratory at least 30 minutes
ang aking dibdib sa time of monitoring of Long-term goals have
rate of 29 bpm, heart after administration of
bawat paghinga ko" vital signs may met. The patient
rate of 120 bpm medication.
as verbalized by the Long-term goal: depend on the peak manifested effective
patient. time of the drug breathing, active
• After 24 hrs. of nursing
administered. participation in desired
• Factory worker • Activity intolerance interventions the patient 3). Assess the patient’s
activities, maintained
related to persistent will demonstrate active activities of daily living, 3). To create a
• (+) hx of sarcoidosis stabilized normal vs.
fatigue as evidenced by participation in as well as actual and baseline of activity
and verbalized
verbalization of necessary and desired perceived limitations to levels and mental
absence of pain.
unrelieved fatigue, activities and physical activity. Ask status related to
Objective data:
overwhelming lack of demonstrate increase in for any form of exercise fatigue and activity
• Pain scale: 9/10 energy, generalized activity levels. that he/she used to do intolerance.
weakness, and
• (+) facial grimace shortness of breath upon • after 1 week of nursing or wants to try.
exertion interventions the patient
• (+) restlessness 4). Encourage 4). To gradually
will maintain active
progressive activity increase the patient’s
participation in
through self-care and tolerance to physical
necessary and desired
VS: exercise as tolerated. activity. To allow the
activities, maintain
Explain the need to patient to pace activity
• PR - 120 bpm effective breathing
reduce sedentary versus rest.
pattern, and stabilized
• RR - 29 bpm activities such as
normal vital signs.
watching television and
using social media in
long periods. Alternate
periods of physical
activity with 60-90
minutes of undisturbed
rest.

5). Elevate the head of 5). To increase the

the bed if the patient is oxygen level and

short of breath. achieve an SpO2

Administer value within the target

supplemental oxygen, range.

as prescribed.
Discontinue if SpO2
level is within the target
range, or as ordered by
the physician.

6). Teach deep 6). To allow the

breathing exercises patient to relax while
and relaxation at rest and to facilitate
techniques. Provide effective stress
adequate ventilation in management. To
the room. allow enough
oxygenation in the
room.
7). Place the patient in
7). Stress may further
complete bed rest
increase pain levels.
when in severe pain.
Educate patient on
stress management,
deep breathing
exercises, and
relaxation techniques.

Collaborative:

8). Refer the patient to

8). To provide a more
physiotherapy /
specialized care for
occupational therapy
the patient in terms of
team as required.
helping him/her build
confidence in
 increasing daily
physical activity.

11. Pulmonary Embolism

A pulmonary embolism (PE) is a blood clot that develops in a blood vessel in the body (often in the leg). It then travels to a lung artery where it suddenly blocks blood flow.

Causes:

People at risk for developing a blood clot are those who:

 Have been inactive or immobile for long periods of time due to bed rest or surgery.
 Have a personal or family history of a blood clotting disorder, such as deep vein thrombosis (DVT) or pulmonary embolism (PE).
 Have a history of cancer or are receiving chemotherapy.
 Sit for prolonged periods.

Clinical Manifestations:

Symptoms may include:

 Sudden shortness of breath

 Unexplained sharp pain in chest, arm, shoulder, neck or jaw. The pain may also be similar to symptoms of a heart attack.
 Cough with or without bloody sputum (mucus).
 Pale, clammy or bluish-colored skin.
 Rapid heartbeat (pulse).
  Excessive sweating.
 Feeling anxious, light-headed, faint or passing out.
 Wheezing.

Nursing Care Plan

Assessment Nursing Diagnosis Planning Implementation Rationale Evaluation

Subjective data: Ineffective breathing Short term: Independent: Short-term goal has
pattern may be met. After 8 hrs of
"Sobrang sumasakit After 8 hrs of nursing 1). Assess the client’s 1).Pulmonary embolism
related to chest pain nursing interventions,
ang dibdib ko sa interventions the client anxiety level. is a sudden acute
and hypoxia as the client manifest
bawat oras na should manifest condition that can
evidenced by effective breathing
humihinga ako at effective breathing and a produce anxiety. Anxiety
desaturation, and a decrease in
madalas akong decrease in pain scale can result in rapid,
dyspnea, impaired pain scale from 8/10 -
nahihirapan of 8/10 shallow respirations and
chest excursion, 1/10.
huminga" as increase dyspnea. It can
tachypnea,
verbalized by the be a sign of decreasing
tachycardia, and
patient Long term: hypoxemia.
restlessness. Long-term goal has
After 24 hrs. of nursing 2). Respiratory rate and met. The patient
2). Assess the rhythm changes are manifest absence of
interventions the patient
Objective Data: respiratory rate, rhythm,
will maintain effective early signs of impending dyspnea and stable
and depth. Assess for respiratory distress. vital signs. The patient
Pain scale: 8/10 breathing pattern, as
any increase in the work Tachypnea is a typical has effectively
evidenced by relaxed
Facial grimace is of breathing: shortness
breathing at normal rate finding of pulmonary maintained normal
present and depth, and absence of breath, and the use of embolism (PE). The breathing pattern.
of dyspnea. accessory muscle. rapid, shallow
VS:
respirations results from
•BP - 140/100 hypoxia. The
development of
•RR - 31 bpm
hypoventilation (slowing

•PR - 89 bpm of respiratory rate)

without improvement in
•O2 Sat - 79% the client’s condition
indicates respiratory
Appearance:
failure.
Cyanotic

3). Pain is usually sharp

3). Assess the
or stabbing and gets
characteristics of pain,
worse with deep
especially in association
breathing and coughing.
with the respiratory
It can result in shallow
cycle.
respirations, further
impairing effective gas
exchange.

4). ABGs of these

4). Monitor arterial blood
clients typically exhibit
gasses (ABGs).
hypoxemia and
respiratory alkalosis
from a blowing off of
 carbon dioxide. The
development of
respiratory acidosis in
this client indicates
respiratory failure, and
immediate ventilator
support is indicated.

5). Monitor oxygen 5). Pulse oximetry is a

saturation as indicated. useful tool in the clinical

setting to detect
changes in oxygenation.
Oxygen saturation
should be at 90% or
greater on room air.

6). Provide reassurance 6). The presence of a

and allay anxiety by trusted person may be
staying with the client helpful during periods of
during acute episodes of anxiety.
respiratory distress.
7). If not
7). Position the client in contraindicated, a sitting
a sitting position, and position allows good
change the position lung excursion and
every 2 hours. chest expansion.
Repositioning facilitates
 movement and the
drainage of secretions.

8). Coughing is the most

8). Encourage deep
productive way to
breathing and coughing
remove secretions. The
exercise. Suction as
client may be unable to
indicated.
perform independently.
Suctioning is indicated
when clients are unable
to remove secretions
from the airways by
coughing. These
maneuvers help keep
airways open by
clearing secretions.
Collaborative::
9). Common tests such
9). Prepare the client for as a chest x-ray
diagnostic studies: examination and D-
dimer assay ( a marker
 Chest X-ray
for clot lysis) are readily
 Computed
available in acute care
tomography
settings, especially to
(CT) scan
rule out PE. If there is a
 Ventilation-
high suspicion for PE,
perfusion scan
  Pulmonary then a CT scan and
arteriogram other scans are added
 D-dimer assay to make a diagnosis. A
pulmonary arteriogram
is a definitive test.

10). Administer oxygen

10). Supplemental
as indicated.
oxygen maintains
adequate oxygenation,
decreases the work of
breathing, relieves
dyspnea, and promotes
comfort. The appropriate
amount of oxygen needs
to be continuously
delivered so the client
does not become
desaturated.

11). Intubation and

11). Anticipate the need
positive-pressure
for intubation and
ventilation are a means
mechanical ventilation.
to stabilize breathing
and ventilation and
prevent decompensation
of the client.