BSN4A (GROUP 2) 33 XI.

Nursing Care Plan Assessment Data Actual Abnormal Cues: Moderately advanced PTB on left lung, with gaseous necrosis formation Pleural effusion on right lungs with Chest Tube Thoracotomy(CTT) of 350 Anemia Ateriosclerotic aorta Difficulty breathing Verbalized, indi ko ka ginhawa tadlong kay sa kilid ko ni nga tubo, kasakit kung mag ginhawako Wheezing upon auscultation in left lower quadrant of the lungs Crackles upon auscultation in the left upper quadrant of lungs Nursing Diagnosis Impaired Gas Exchange related to altered oxygen supply due accumulation of fluid in the pleural space, presence of viscous secretions, decrease in effective lung surface as evidenced by difficulty of breathing, chest pain, tachypnea, wheezing and crackles upon auscultation, CTT of 350 cc Rationale Predisposing Factors Gender: Male Biological: History of TB infection Precipitating Factors Close contact with infected person Low income group Poor medical care Coexisting disease in the community Cigarette smoking Exposure or inhalation of infected aerosol through droplet by Mycobacterium tuberculosis Tubercle bacilli invasion in the apices of the lungs or near the pleurae of the lower lobes Bronchopneumonia develops in the lung tissue (phagocytised tubercle bacilli are ingested by Desired Outcome After 32 hours of nursing intervention, the client will be able to: 1. Report absence/ decrease dyspnea Nursing Intervention Justification Evaluation After 32 hours of nursing intervention, the client was be able to:

Independent:

Independent:

1.1 Asses respiratory 1.1 Manifestations rate, depth, and of respiratory ease distress are dependent on/ indicative of the degree of lung involvement and underlying health status. 1.2 Assess for dyspnea (using 0-10 scale), tachypnea, abnormal/dimini shed breath sound, increased respiratory effort, limited chest wall expansion, and fatigue

Definition: Excess or deficit in oxygenation and/or carbon dioxide elimination at the

1. Goal partially met. Experienced shallow breathing and pain upon inhalation due to his tube drainage as mentioned by the patient. He is not in labored breathing and does not use his 1.2 Pulmonary TB accessory muscle can cause a wide and exert not much range of effects effort upon in the lungs, inhalation. ranging from a small patch of bronchopneumo nia to diffuse inflammation, caseous necrosis, pleural effusion, and extensive fibrosis.

BSN4A (GROUP 2) 34 Wheezing to diminished breath sound on the right lung Limited chest wall expansion Shallow, rapid breathing RR of 36cpm Exert effort upon inhalation Lethargic Fatigue alveolar-capillary membrane (This may be an entity of its own, but it also be an end result of other pathology with an interrelatedness between airway clearance and/or breathing pattern problems) macrophages), bacterial cell wall binds with macrophages Inflammation of the lung tissues and pleura Necrotic degeneration occurs (production of cavities filled with cheese-like mass of tubercle bacilli. Dead WBCs, necrotic lung tissue) Impaired lung tissues and capillary function Impaired lymphatic drainage of the pleural space Transdiaphragmatic movement of inflammatory fluid from the peritoneal space Altered permeability of pleural membranes Increased capillary wall permeability or vascular disruption Respiratory effects can range from mild dyspnea to profound respiratory distress. 1.3 Maintain bed 1.3 Reducing rest/limit activity oxygen and assist with consumption. self-care Demand during activities as periods of necessary. respiratory compromise may reduce severity of symptoms.

Risk Related Factors: Malnutrition Infection History of smoking Poor family support Poor financial support

Strengths: Willingness to get well Good compliance to medication

Source: Nurses Pocket Guide 11th Edition by Doenges, Moorhouse and Murr

2. Demonstrate improved ventilation and adequate oxygenation of tissues

2.1 Observe color of skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis (nailbeds) or central cyanosis (circumoral).

2.1 Cyanosis of nail beds may represent vasoconstrictio n or the bodys response to fever/chills; however, cyanosis of earlobes, mucous membranes, and skin around the

2. Goal partially met. Have a good capillary refill of less than 2 seconds and able to breathe on his own capacity. He was more calm and able to rest more without difficulty. But, patient still experienced fatigue, lethargy and dyspnea.

BSN4A (GROUP 2) 35 Increase accumulation of fluids in the lungs Impaired Gas Exchange 2.2 Avoid patient to lie down on operative side; instead , favor the good lung down position mouth (warm membranes) is indicative of systemic hypoxemia 2.2 Research shows that positioning patients following lung surgery with their good lung down maximizes oxygenation by using gravity to enhance blood flow to the healthy lung, thus creating the best possible match between ventilation and perfusion. 3. Goal met. Participate actively in the activities as tolerated. He tried to do deep breathing and coughing exercise

3. Participate in actions to maximize oxygenation.

3.1 Demonstrate/enc ourage purse-lip breathing during exhalation.

3.1 Creates resistance against outflowing or to prevent collapse/narrow

BSN4A (GROUP 2) 36 ing of the airways, thereby helping distribute air throughout the lungs and relieve/reduce shortness of breath. 3.2 Elevate head of bed, change position frequently. 3.2 Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. 3.3 Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural selfcleaning mechanism, assisting the cilia to even if he experience pain due to his chest tube. Also, he can follow instructions accordingly.

3.3 Assist patient with deepbreathing exercises. Demonstrate/hel p patient learns to perform activity, e.g., splinting chest and effective coughing while in upright position.

BSN4A (GROUP 2) 37 maintain patent airways. Splinting reduces chest discomfort, and upright position favors deeper, more forceful cough effort. 3.4 Provide appropriate chest physiotherapy, including postural drainage and breathing exercise. 3.4 Aids in clearing secretions, which improves ventilation, allowing excess CO2 to be eliminated.

Collaborative: 1. Provide supplemental oxygen as appropriate

Collaborative: 1. Aids in correcting the hypoxemia that may occur secondary to decrease ventilation/ diminished alveolar surface 2. Tube Care: Chest a. Drains fluid

2. Tube Care: Chest a. Maintain

BSN4A (GROUP 2) 38 patency of chest drainage system. from pleural cavity to promote reexpansion of remaining lung segments. b. Bloody drainage should decrease in amount and change to a more serous composition as recovery progresses. A sudden increase in amount of bloody drainage or return to frank bleeding suggests thoracic bleeding/ hemothorax; sudden cessation suggests blockage of tube, requiring further evaluation and intervention.

b.Note changes in amount/type of chest tube drainage.

BSN4A (GROUP 2) 39 c. Observe presence/degree of bubbling in water-seal chamber. c. Air leaks immediately postoperative are not uncommon; however this should diminish as healing progresses. Prolonged or new leaks require evaluation to identify problems in patient versus the drainage system.

BSN4A (GROUP 2) 40 Assessment Actual/ Abnormal Cues Diagnosis Rationale Predisposing Factors Gender: Male Biological: History of TB infection Precipitating Factors Close contact with infected person Low income group Poor medical care Coexisting disease in the community Cigarette smoking Presence of fluid in the lungs CTT is attached Inflammation of the CTT insertion site Tissue damage Activation of the Desired Outcome After 32 hours of nursing intervention patient will be able to: Nursing Intervention Justification Evaluation After 32 hours of nursing intervention patient was able to:

Acute pain related to presence of Patient insertion site of verbalized,kasaki CTT (Chest Tube tkaakondughanng Thoracotomy) as a may tubo evidenced by presence of guarding insertion site of behavior, facial CTT mask, reported guarding behavior sleep disturbance facial mask and restlessness. reported sleep disturbance restlessness PR= 100cpm RR= 40 cpm

1. Manage self when pain occurs.

1.1 Acknowledge the pain experience and convey acceptance of clients response to pain.

1.1Reduces defensive responses, promotes trust and enhances cooperation with regimen. 1.2Relaxation skills and techniques have no detrimental side effects. 1.3To provide patient education and to the S.O.

1. Goal met. Patient performs deep breathing exercise when he is in pain and was seen changing his position.

1.2 Review non pharmacologic measures for lessening pain. 1.3 Provide information/ discuss pain management.

Strengths: Willingness to get well Good compliance to medication Weakness: poor compliance to medication poor family support financial constraints

Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described or in terms of such damage.

2. Verbalized non pharmacologic methods that provide pain relief.

2.1Instruct/ encourage use of relaxation techniques such as focused breathing and imaging. 2.2Provide health teaching regarding non pharmacologic methods to relieve pain.

2.1To distract attention and reduces tension.

2.2To provide information to the client so that he will be able to manage pain by himself.

2. Goal met. Patient verbalized. gaginhawa lang ko dalum para maibanan ang sakit kag kung kaisa gina lain ko ang konposisyon.

3. Report pain is

3.1Provide comfort

3.1To promote non

3. Goal met. Patient

BSN4A (GROUP 2) 41 peripheral nervous relieved/ controlled. system Activation of central nervous system and transmission of pain at the spinal cord level Transmission of pain signal to the brain Acute pain related to presence of insertion site of CTT measures such (eg. Touch, repositioning, use of heat/ cold packs), quiet environment and calm activities. 3.2Administer analgesics, as indicated, to maximum dosage, as needed. pharmacologic pain management. reports, gaka ibanan man ang sakit katapos kapilaka minute gakadula man ang sakit.

Source: Nurses Pocket Guide. 11th Ed. Doenges, Moorhouse and Murr.

3.2To maintain acceptable level of pain. Notify physician if regimen is inadequate to meet pain control goal.

BSN4A (GROUP 2) 42 Assessment Data Risk Related Factors Presence of right (CTT) Chest Tube Thoracotomy Foul smelling discharges coming out from the incision site Poor dressing of incision site Poor hygiene Nursing Diagnosis Risk for injury related to therapeutic puncture of lung secondary to iatrogenic pneumothorax Rationale Predisposing Factors Biological: History of TB infection Precipitating Factors Low income group Poor medical care Poor hygiene Presence of CTT Dislodgment in place of CTT in the pleural cavity Potential puncture of CTT to the intrapleural space or leakage in the lung Introduction of air to the intrapleural space Allow air to enter and gather around the lungs Desired Outcome After 32 hours of nursing intervention, the client will be able to: 1. Identify individual risk factors. 1.1 Ask about chest pain; determine its onset, intensity, and location. Ask if the patient has shortness of breath or difficulty in breathing or fatigue. 1.2 Check the patients history for bleeding disorders or anticoagulant therapy. 1.3Examine the patients chest for a visible wound that may have been caused by a penetrating object. 1.1Elicit a history of COPD or emphysema or if the patient has had a thoracotomy, thoracentesis, or insertion of a central line. Nursing Intervention Justification Evaluation After 32 hours of nursing intervention, the client was be able to:

Weakness: Malnutrition Infection History of smoking Poor family support Poor financial support

Definition: At risk for injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources

1. Goal met. Patient verbalized, ang ginhalinan sang sakit ko guru amu ang pag-inom ko kg pag panigarilyo tapus gaubra pa ko sa kampo nga naga-tagi-ti ang init.

1.2 To properly manage of underlying conditions

Source: Nurses Pocket Guide 11th Edition by Doenges, Moorhouse and Murr

1.3Patients with an open pneumothorax also exhibit a sucking sound on inspiration.

Strengths: Willingness to get well

2. Modify environment , as indicated, to

2.1Elevate the head of the bed to facilitate breathing. Instruct client to lie on the unaffected side with the head of the bed elevated

2.1 This position facilitates expansion of the affected lung and eases respirations

2. Goal met. Patient elevates his head when he has difficulty in breathing and uses deep

BSN4A (GROUP 2) 43 Good compliance to medication Collapsed of the lungs Risk for injury related to therapeutic puncture of lung secondary to iatrogenic pneumothorax Source: Nurses Pocket Guide 11th Edition by Doenges, Moorhouse and Murr 3. Take safety precautions during the span of stay in the hospital enhance safety and use resources appropriatel y 30 degrees for at least 30 minutes 2.2 Obtain a chest X-ray. 2.2To determine the chest tube placement. 2.3To early manage symptoms and prevent further injury breathing exercises as instructed.

2.3Immediately report signs and symptoms of pneumothorax, tension pneumothorax, and pleural fluid reaccumulation such as difficulty of breathing and chest pain.

3.1Monitor vital signs, pulse oximetry, and breathe sounds.

3.1 To have baseline data and note any deviation of succeeding readings most especially the respiratory rate

3.2 Observe the puncture site and dressings. 3.2 To note for any leakage and discharges that may precipitate pneumothorax

3. Goal met. Patient observes safety precautions in the hospital and the folk never leave the patient alone.