Name: R.M.

Age/Sex: 69/M

CC: Dyspnea

Diagnosis: Spontaneous pneumothorax secondary to COPD; CAP-MR; post CTT insertion

Date &
time
08/14/1
5
@ 8 AM

Cues
S: Maglisod kog
ginhawa. As
verbalized by the
patient.
O:
With CC of
dyspnea
With Dx of
spontaneous
pneumothorax;
COPD; CAP-MR
(+) recurrent
cough
(+) yellow; thick
tenacious
sputum
(+) exertional
dyspnea

With observed
rapid -shallow

Nee
d
A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E
P
A
T
T
E
R
N

Rm. Bed no: 407-3

Nursing
Diagnosis
Ineffective
breathing pattern
r/t decreased lung
expansion aeb:
dyspnea
secondary to
pneumothorax.
R:
Pneumothorax
results from break
in the chest wall,
or the lung,
allowing air into
the pleural space.
Air flows directly
into the pleural
cavity. As the air
pressure in the
pleural cavity
becomes positive,
the lung collapses
on the affected
side, resulting in
substantially
decreased total
lung capacity, vital

AP: Dr. Ma. Evangelina C. Durban

Objective of care

Nursing interventions

After my 7 hours of
nursing interventions
the pt. will establish an
effective respiratory
pattern aeb:

1. Check out
respiratory
function, noting
rapid or shallow
respirations,
dyspnea,
development of
cyanosis, changes
in vital signs.
R: respiratory distress
and changes in VS may
occur as a result of
physiological stress and
pain or may indicate
development of shock d/t
hypoxia or hemorrhage.
2. Auscultate breath
sounds.
R: Regularly scheduled
evaluation also helps
determine areas of good
air exchange and
provides a baseline to
evaluate resolution of
pneumothorax.
3. Note chest
excursion and

a. Absence of
dyspnea upon
activity
b. Respiratory
rate maintained
at normal
range (16-20
cpm)
c. Clients
verbalization of
improvement in
respiration.

Evaluation
08/14/15 @ 3 PM
GOAL PARTIALLY
MET.
After my 7 hours of
nursing interventions
the pt. established
an effective
respiratory pattern
aeb:
a. Dyspnea not
manifested
b. R=24cpm
c. Dili na
paspas
akong
ginhawa, ug
wala nako
ginahangak.
As
verbalized by
the patient.
Cazze Lynn Sunio
St.N

breathing
With medications
of ipatropium
bromide,
NAcetylecysteine,
celecoxib
With CTT on
Right
With O2 @
2L/min via nasal
cannula
Positioned on
moderate high
back rest
With VS of:
T- 35.8
C- 74
P- 72
R- 25
BP- 130/80

capacity, and lung

compliance. The
resulting
ventilationperfusion
imbalances lead
to hypoxia.

position of
trachea.
R: chest excursion is
unequal until lung reexpands. Trachea
deviates away from
affected side with tension
pneumothorax.
4. Evaluate fremitus
R: voice and tactile
fremitus is reduced in
fluid-filled or consolidated
tissue
5. Encourage to
increase intake of
oral fluids.
R: adequate fluid intake
enhances liquefication of
pulmonary secretions and
facilitates expectoration of
mucus.
6. Assist pt. with
splinting painful
area when
coughing, deep
breathing
R: supporting chest and
abdominal muscles
makes coughing more
effective and less
traumatic.
7. Maintain position

of comfort, usually
with head of bed
elevated. Turn to
affected side.
Encourage pt. to
sit up as much as
possible.
R: promotes maximal
inspiration; enhances
lung expansion and
ventilation in unaffected
side.
8. Check suction
control chamber
for correct amount
of suction
(determined by
water level, wall or
table regulator at
correct setting.
R: water in a sealed
chamber serves as a
barrier that prevents
atmospheric air from
entering the pleural
space. The suction
source aids in evaluating
whether the chest
drainage system is
functioning properly.
9. Observe waterseal chamber

bubbling.
R: bubbling during
expiration reflects venting
of pneumothorax.
Absence of bubbling may
represent complications
such as obstruction in the
tube.
10. Seal drainage
tubing connection
sites securely with
lengthwise tape or
bands according
to established
hospital policy.
R: prevents and corrects
air leaks at connector
sites.
11. Administer
supplemental O2
via cannula, mask
or mechanical
ventilation as
indicated.
R: aids in reducing work
of breathing; promotes
relief of respiratory
distress and cyanosis
associated with
hypoxemia.