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NCP PROPER # 1 EXPLANATION OF THE NSG DOAGNOSIS S> Nahihirapan akong Ineffective breathing huminga, parang may pattern

occurs when sumasakal sa akin, tsaka inspiration and expiration marami akong plema. does not provide adequate ventilation. O> With RR of 28 cpm Pleural inflammation > Difficulty of breathing causes sharp pain upon noted deep breathing, > With ongoing coughing and moving. inhalation at full level This can result to LPM via face mask shallow or rapid > With productive cough breathing pattern. characterized as clear with streak of blood Impaired gas exchange amounting to 1 tbsp is a state in which there > Shortness of breath is excess or deficit noted oxygenation and carbon > Use of accessory dioxide elimination. The muscles upon breathing compensatory noted mechanism of lungs is to > Patient is unable to lose effectiveness of its tolerate moderate defense mechanism and fowlers position allow organisms to > With rhonchi and penetrate the lower crackles on both lung respiratory tract where fields upon auscultation inflammation develops. > CT-scan result as of 12/05/11 revealed bilateral pleural effusion > Nasal flaring noted > With capillary refill of 1-2 seconds PROBLEM OBJECTIVE STO: After 8 hours of nursing interventions, the patient will be able to demonstrate improvement of airway patency as evidenced by adequate oxygenation by pulse oximetry & blood gas analysis and effective coughing exercises. LTO: After 3 days of nursing interventions, the patient will be able to apply techniques that will improve breathing pattern and will be free from signs of respiratory distress: respiratory rate is within normal range, absence of cyanosis, effective breathing and minimal use of accessory muscles during breathing. INTERVENTION Dx> monitor vital signs RATIONALE >Monitoring the changes in vital signs is important because it may indicate if a condition becomes worst. (J. Fuzy) > Lesser amount of output than intake may indicate fluid retention. (L. white, 2005) > Respiratory status assessment helps gauge the severity or whether it is progressing. (L. White, 2005) >Circulatory status indicates proper perfusion and oxygenation of patient. (J.L. Vincent, 2010) > Characteristics involve color and amount which indicate problem in the lungs and tracheobronchial tree. (Lippincott Williams and Wilkins, 2006) >A mucolytic agent that breakdown acid mucopolysaccharide fibers making the sputum thinner and less viscous EVALUATION

> Monitor intake and output

> Assess respiratory status

> Assess circulatory status

> Assess characteristics of cough

Tx> Administer ambroxol

> With pitting edema, +2 on right arm > Administer Levopront Nsg Diagnosis: Impaired Gas Exchange related to Ineffective Breathing Pattern related to

> Assist patient in sitting position

> Maintain oxygen therapy as ordered > Regulate IVF as ordered

and therefore easier to remove by coughing. > A cough suppressant that that suppresses the cough reflex by depressing the cough center (Mason, 2002) > To increase chest expansion and by law of gravity, abdominal organs will not compress the diaphragm. >To provide relief from symptoms of hypoxemia and hypoxia. > Over infusion will aggravate and exacerbate the effect of pleural effusion. > Slow but deep breathing allows air to enter the lungs and allow lungs to expand fully. (Lippincott Williams and Wilkins, 2006) >To effectively eliminate secretions. > To decrease oxygen requirement in the body caused by movement.

Edx>Encourage DBE

>Encourage coughing exercise > Encourage bed rest

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