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Air Gets Inside The Chest Cavity

The patient was experiencing difficulty breathing due to ineffective airway clearance related to increased air pressure in the chest cavity from a collapsed lung. The nursing diagnosis was ineffective airway clearance related to lung collapse. The plan was to monitor vital signs and perform nursing interventions like deep breathing exercises, positioning, steam inhalation, and administering medications to improve airway clearance over 3-6 hours. The goal was for the patient to maintain effective airway clearance as evidenced by normal vital signs and absence of symptoms.

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Lore Anne Mhae Santos
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42 views2 pages

Air Gets Inside The Chest Cavity

The patient was experiencing difficulty breathing due to ineffective airway clearance related to increased air pressure in the chest cavity from a collapsed lung. The nursing diagnosis was ineffective airway clearance related to lung collapse. The plan was to monitor vital signs and perform nursing interventions like deep breathing exercises, positioning, steam inhalation, and administering medications to improve airway clearance over 3-6 hours. The goal was for the patient to maintain effective airway clearance as evidenced by normal vital signs and absence of symptoms.

Uploaded by

Lore Anne Mhae Santos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
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Cues Nursing Diagnosis Analysis Planning Nursing Interventions Rationale Evaluation

Subjective: Ineffective airway air gets inside the STG: **Independent Goal met as evidenced
“Nahihirapan po clearance related to chest cavity After 3 hrs of nursing interventions by patient maintain
ako huminga ” as increased air ↓ intervention the patient Monitor VS especially -to obtain baseline data effective airway
verbalized by the pressure secondary Pneumothorax will demonstrate body temp, lab results clearance as evidenced
patient to lung collapse as ↓ behaviors of effective (WBC, Chest Xray, by normal VS and
evidenced by creates pressure airway clearance as Sputum Test) absence of dyspnea,
Objective: dyspnea, against the lung evidenced by normal VS tachycardia, and
-use of accessory tachycardia,use of ↓ and absence of dyspnea, Encourage deep breathing -to expel the mucus and crackles
muscle accessory muscle, Decrease lung tachycardia, and and coughing exercises increase lung expansion
-dyspnea crackles, expansion crackles
-tachycardia restlessness, ↓ Position the patient in a -to facilitate breathing
-crackles noted BP:100/80 T:36.8 Ineffective LTG: semi fowler's position and increase lung
PR: 128bpm, and airway After 6 hrs of nursing expansion
VS: RR: 40cpm clearance intervention the client
BP: 140/90 will maintain effective Promote rest -to reduce metabolic
T: 38.5 airway clearance as demands
PR: 110 bpm evidenced by normal VS
RR: 28 cpm and absence of dyspnea,
O2 Sat: 94 tachycardia, and Encourage steam -to moisten secretions and
crackles inhalation alleviate congestion

**Dependent
Perform thoracentesis as -to remove air from the
ordered lungs

Administer oxygen therapy -to help breath adequately


as ordered and prevent hypoxia

Administer -to reduce bronchospasm


bronchodilators and mobilize secretions
(salbutamol neb) as
ordered
Administer antibiotic -to treat infection and
(ceftriaxone) as ordered inflammation of airways

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