Assessment Subjective: Maglisod ko ug ginhawa, as verbalized by the patient.

Nursing Diagnosis Ineffective Breathing Pattern related to decreased lung expansion

Nursing Goal Within 1 hour of nursing intervention the patient will exhibit normal breathing pattern

Nursing Intervention -Assess respiratory rate depth and effort

Rationale -Respiratory rate and rhythm changes such as increased in respiratory rate with a decreased tidal volume are early warning signs of impending respiratory difficulties

Outcome Criteria Patient maintains effective breathing, as evidence by respiratory rate 12 to 20 breaths/min and clear and clear and equal lung sounds bilaterally. Chest Radiograph shows lungs fully expanded

Actual Evaluation

Objective: Dyspnea Nasal cannula Usedof accessory muscle: elevation of shoulder Nasal flaring RR-24bpm

-Auscultate lungs for area of diminished or absent lung sounds -Asses for pain

-This may indicate partial or complete collapse of the lung -Pain can result in shallow breathing

-Secure connections

-A loose connection can allow air entry and positive

Pressure in the intrapleural space, resulting in further lung collapse

-Intact water seal

-This prevents air entry into the intrapleural space

-Fluctuation of fluid caused by pressure changes in the intrandexpirationapleural space during inspiration

-Cessation of fluctuating of fluid can indicate lung re-expansion or, if abrupt can indicate clog or kinked tube -Bubbling indicartes air removal from the intrapleural space, especially during expiration or coughing. Cessation of bubbling can indicate lung re expansion. Continuous bubbling can indicate air leak

-Check for bubbles

within the patients chest within the system

-Assess feeling of dypnea or shortness of breath

-This may indicate hypoxia

-Assess vital signs, including temperature

-Tachycardia is common during hypoxia

-Asses mentation for signs of hypoxia and hypercapnia

-Restlessness, inappropriateness, lethargy and confusion may result with haypoxia and hypercapnia

-Assess chest drainage system

-An intact system reduces the risk for infection

-Assess chest tube drainage for increased or purulent drainage

-This may represent infection and require culturing

-Assess chest tube insertion site for reddened wound edges.

-This may be early signs of infection

-Assess WBC Count

-Rising WBC count indicates the bodys effort to combat pathogens

-Administer supplemental oxygen as required

-This maintains oxygen 90% for greater adequate oxygenations

-Elevate head of the bed

-This enhances lung expansion

-Use incentive spirometry as needed

-This enhances breathing there by decreasing Potential for atelectasis

Assessment Su Mosakit akong kilid (duol sa akong tube inig ubo nako,

Nursing Diagnosis Acute pain related to trauma

Nursing Goals Short Term Goals Patient will report pain less than 3 on 0-10 scale. Patients vital signs will be within normal limits. Long Term Goal Patient will be free of pain

Nursing Intervention -Assess pain characteristics: quality (sharp, burning); severity (0 -10 scale); location; onset (gradual, sudden); duration (how long); precipitating or relieving factors.

Rationale -A good assessment of pain will help in the treatment and ongoing management of pain.

Outcome Criteria

Actual Evaluation

-Monitor vital signs.

-Tachycardia, elevated blood pressure, tachypnea and fever may accompany pain.

-Assess for nonverbal signs of pain.

-Some patients may verbally deny pain when it is still present. Restlessness, inability to focus, frowning, grimacing and

guarding of the area may be nonverbal signs of acute pain.

-Give analgesics as ordered and evaluate the effectiveness

-Narcotics are indicated for severe pain. Pain medications are absorbed and metabolized differently in each patient, so their effectiveness must be assessed after administration.

-Assess the patients expectations of pain relief.

-Some patients are content with reduction in pain, others may expect complete elimination. This effects the patients perception of the effectiveness of treatment

-Assess for complications to analgesics, especially respiratory depression.

- Excessive sedation and respiratory depression are severe side effects that need reported immediately and may require discontinuation of medication. Urinary retention, nausea/vomiting and constipation can also occur with narcotic use and need reported and treated.

- Anticipate the need for pain relief and respond immediately to complaints of pain.

- The most effective way to deal with pain is to prevent it. Early intervention can decrease the total amount of analgesic required. Quick response decreases the patients anxiety

regarding having their needs met and demonstrates caring.

- Eliminate additional stressors when possible. Provide rest periods, sleep and relaxation

- Outside sources of stress, anxiety and lack of sleep all may exaggerate the patients perception of pain

- Institute nonpharmacological approached to pain (detraction, relaxation exercises, music therapy, etc.)

- Nonpharmacological approaches help distract the patient from the pain. The goal is to reduce tension and thereby reduce pain