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CNU-CN FORM 002

Mission-Vision: Care Using Knowledge and Compassion

Cebu Normal University College of Nursing Cebu City

NURSING CARE PLAN


NCP Scoring System Nursing Dx 10 pts 2 pts Defining Characteristics Outcome 3 pts 1 pt Intervention Bibliography 3 pts 1 pt (at least 5 references)

Clients Name: ___Rosemarie Cohitmingaw ___ ____________________________ Age: _27__ Sex: __F__ Civil Status: _Married___ Religion: __Roman Catholic_______ Allergies: Food: ___dried fish, gabi _________________________________________ Drug: ____ no known drug allergies ________________________________ Diet: __Diet as Tolerated_________________________________________________ Date of Admission: __June 29, 2010________________________________________ Diagnosis: Gunshot wound, POE: L intrascapular area; POX: L 5th intercostals space__ ____________________________________________________________

Patient Care Classification: (Please Check) __________ Wholly Compensatory: Pts. therapeutic self-care is accomplished by nurse __________ Partially Compensatory: Pts. performs some self-care measures _________ Supportive Educative: Pts. accomplishes self-care measures Clinical Division and Bed No: __VSMMC Ward 1 Bed 8________________________ Name of Physician: _Dr. Alfeche__________________________________________ Name of Student: __Jennifer Kaye L. Ducao_CNU CN Batch 2012_______________

DEFINING CHARACTERISITICS Nursing Diagnosis: Ineffective breathing pattern related to decreased lung expansion 2 hemothorax S: Kutasan kaau ko. Grabe kalisud muginhawa. as verbalized. O: - received on bed, awake, conscious, coherent, s IVF, with CTT at left thoracic area,- temporarily closed, with dry, intact dressing at insertion site, alterarion in depth of breathing, nasal flaring and occassional pursed lip breathing observed, respiratory rate of 36 cycles per minute

EXPECTED OUTCOME CRITERIA (Ideal) SHORT TERM GOAL After 4 hours of nursing interventions, the patient will be able to verbalize awareness of condition. Patient will be able to establish an improvement in respiratory rate, depth, and pattern LONG TERM GOAL After 3 days of nursing intervention, pt will be able to establish a normal and effective breathing pattern within her normal range. Patient will demonstrate skill in conserving energy while carrying out activities of daily living (ADLs).and initiate needed lifestyle changes.

INTERVENTION AND RATIONALE Independent


I: Assess lung sounds, respiratory rate and effort and the use of accessory muscles. R:Respiratory rate less than 12 or more than 24 or use of accessory muscles indicate distress. Diminished lung sounds indicate possible poor air movement and impaired gas exchange. S: Ignativicius, 618 I: Monitor Vital signs R:To have baseline data and for comparison for future data & to evaluate the degree of compromise. S: scribd.com I: Encourage to take slow, deep breaths, to turn, and to cough. R: effective aeration and cough will hekp rid of secretions that aters breathing. Frequent positioning will prevent secretions from pooling. S: Ignativicius, 618

BEHAVIORAL OUTCOME (Actual) Bibliography:


Doenges et al Nurses Pocket Guide 2008. Philadelphia: F. Davis Kozier et al. Fundamentals of Nursing. 5th Ed. Singapore Pearson Education Inc. 2002

Understanding Medical-Surgical Nursing 3rd Edition by William, L. Hopper Ignativicius et al. Medical-Surgical Nursing 5th Ed. Elsevier Saunders Pte Ltd. 2006 Medical-Surgical Nursing 8th Edition by Black and Hawks

http://nursingcrib.com/ http://scribd.com/ http://wikipedia.org/ http://eMedicineHelp.com/ http://healthline.com/

DEFINING CHARACTERISITICS Laboratory:


Patient underwent several Chest X-rays. Results are continuously verified, thus repeat Chest Xrays are ordered.

EXPECTED OUTCOME CRITERIA (Ideal)

INTERVENTION AND RATIONALE


I: Position to Semi Fowler's Position, if possible R: Ensures that abdominal contents do not press against the diaphragm and restrict chest expansion. S: Ignativicius, 618 I: Encourage liberal amount of fluids R: fluids will help keep lung secretions thin and easier to cough out of the airways S: Ignativicius, 618

BEHAVIORAL OUTCOME (Actual)


I: Monitor for increased restlessness, anxiety and air hunger. R: A change in the LOC is the earliest sign of deterioration in effective oxygenation. S: Ignativicius, 618 I: Encourage assistance going to CR R: To prevent falls due to lack of oxygen S: healthline.com I: Provide comfort measures & ensure patient safety R: Provide comfort and body support S: Doenges (2008) p.324 I: Instruct pt to conserve energy such as standing and walking only when necessary R: Activity increases circulation and intraabdominal pressure. S: Doenges, 324

Theoretical Basis:
Rosemarie Cohitmingaw, 33, F, Married, was admitted for the first time at VSMMC Ward 6 with a final diagnosis of Gunshot wound, POE: L intrascapular area; POX: L 5th intercostals space AAL. CTT insertion was performed. On July 11, 2010, reinsertion was made. Patient complains of shortness of breath especially when moving. Patient has a respiratory rate of 36 cpm. Chest tubes are inserted to drain blood, fluid, or air and to allow the lungs to fully expand. The tube is placed between the ribs and into the space between the inner lining and the outer lining of the lung (pleural space). They are used to treat conditions that can cause the lung to collapse, such as after surgery or trauma in the chest: pneumothorax or hemothorax. (Medicine Plus) A hemothorax is the accumulation of blood between the membranes lining the lungs. A pneumothorax on the other hand is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. (wikipedia.org) The lung contains gas, blood, thin alveolar walls and support structures. The alveolar wall contains elastic and collagen fibers; these form a three-dimensional basket-like structure that allows the lung to inflate in all directions. These fibers are capable of stretching when a pulling force is exerted on them from outside of the body or when they inflate from within. The elastic recoil helps return the lungs to their resting volume. If air or increased amounts of serous fluid, blood, or pus accumulate in the thoracic space, it may hinder adequate lung expansion and causes the pleural membranes (essential for diffusion of gases) to compress thus respiratory difficulties follow. (Black and Hawks) NANDA defines Ineffective Breathing Pattern as the Inspiration and/or expiration that does not provide adequate ventilation. (Doenges)
The problem needs to be quickly recognized and corrected.

I: Encourage adequate rest and limit activities within clients level of tolerance. R: Helps limit oxygen needs and consumption. S: nursingcrib.com I: Promote a calm and restful environment. R: to prevent stress S:eMedicineHelp.com I: Evaluate peripheral pulses. R: This reflects adequacy of circulating volume. S: Kozier (2002) Dependent I: Folow up chest X-ray results R: The chest tube stays in place intil x-rays show that all blood, fluid or air has fully re-expanded. S: wikipedia.org I: Administer Salbutamol neb q6 as prescribed by the physician. R: usually given by the inhaled route for direct effect on bronchial smooth muscle. S: wikipedia.org I: Collaborate with the client/family and the rehabilitation team. R: Effective interdisciplinary interventions facilitate the client's ability to manage his/her life. S: Ignativicius, 622