NCP For Hemothorax

 

Patient X Chief complaint: Difficulty of breathing Gender: Male Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wound Cues ( Subjective/ Objective) Subjective: “Nakukurian gad ako  pag ginhawa.” as verbalized by the  patient.

Objective: - respiratory rate of 26 cycles per minute - dyspnea - alteration in depth of   breathing - nasal flaring - pursed lip breathing

N   ursing Diagnosis

Ineffective breathing  pattern related to decreased lung expansion

Rationale

The lung contains gas,  blood, thin alveolar  walls and support structures. The alveolar  wall contains elastic and collagen fibers; these form a threedimensional basketlike 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

Age: 42 years old

Goal of Care

After 1 hour of nursing interventions, the client will: 1. Establish a normal and effective breathing  pattern within client’s normal range.

Nursing Intervention

Rationale

Evaluation

Independent: GOAL MET. 1. Identify etiology or   precipitating factors.

Understanding the cause is necessary for  choice of therapeutic measures.

2. Monitor vital signs.

Monitoring the vital signs is necessary evaluate the degreetoof  compromise.

3. Assess lung sounds, respiratory rate and effort and the use of  accessory muscles.

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.

4. Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air  hunger,” and changes in vital signs.

Respiratory distress and changes in vital signs occur as a result of physiologic stress and pain, or may indicate development of shock due to hypoxia or  hemorrhage.

Within 1 hour of  nursing care, the  patient stated acceptable dyspnea. “Mas na akonakakaginhawa hin maupay kesa kanina.” In addition, the patient  participated in treatment regimen. Vital signs are within normal range.

 

difficulties follow. Sources: Medical-Surgical  Nursing 8 th Edition by Black and Hawks Understanding Medical-Surgical  Nursing 3 rd Edition by William, L. Hopper 

Cyanosis indicates 5. Observe skin and mucous membranes for   poor oxygenation. Oral mucous membrane signs of cyanosis. cyanosis indicates serious hypoxia. 6. Encourage adequate rest and limit activities within client’s level of  tolerance. Promote a calm and restful environment.

Helps limit oxygen needs and consumption.

Dependent: 1. Administer oxygen supplemental as ordered by the  physician.

Supplemental oxygen decreases hypoxia.

2. Administer  medications as  prescribed by the  physician.

To treat underlying conditions.

 

Patient X Chief complaint: Difficulty of breathing Gender: Male Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wound Cues ( Subjective/ Objective) Subjective: “Na kirot an didi may tungod ha ak tubo.” as verbalized by the  patient.

Objective: - guarding behavior,  protective gestures,  positioning to avoid  pain - facial mask of pain - narrowed focus

Age: 42 years old

N   ursing Diagnosis

Rationale

Goal of Care

Acute pain related to  presence of tubes and drains

The effect of  anesthesia can be diminished after the  patient has been fully awakened and conscious. The hole made by incision and insertion of the tube

Within 8 hours of  nursing interventions, the client will:

can be painful as cause movements often tension and “pull” to the tube thus the  perceived pain.

out of 10 in pain scale.)

1. Report pain relieved or controlled. (State that the pain is relieved from the scale of 3-5

2. Verbalize at least 2 non-pharmacologic methods that provide relief.

Nursing Intervention

Independent: Good assessment must guide treatment.

2. Assess vital signs noting tachycardia,

Changes in these vital signs often indicate

hypertension and increased respirations, even if client denies  pain.

acute pain and discomfort. Note: Some clients may have a slightly lowered BP, which returns to normal range after pain relief is achieved.

3. Appears relaxed, able to rest or sleep and 3. Assess causes of   participate in activities  possible discomfort

Discomfort can be caused or aggravated

rd

 Nursing 3 Edition by William, L. Hopper 

appropriately.

Evaluation

GOALS MET.

1. Assess pain every four hours and as needed.

Source: Understanding Medical-Surgical

Rationale

other than operative  procedure.

 by presence of non patent indwelling catheters, parenteral lines (bladder pain, gastric fluid and gas accumulation, and infiltration of IV fluids or medications).

4. Provide information

Understanding the

about transitory nature of discomfort, as appropriate.

cause of the discomfort  provides emotional reassurance.

The patient’s pain was relieved as evidenced  by pain scale of 4 out of 10. The patient verbalized method that  provided relief such as the pain medication given, distraction techniques by constantly talking to significant others.

 

5. Reposition as indicated. (Example: semi-Fowler; lateral Sims’)

May relieved pain and enhance circulation. semi-Fowler’s position relieves abdominal muscle tension and arthritic back muscle tension, whereas lateral Sims’ will relieve dorsal pressure.

6. Provide additional comfort measures; e.g.,  backrub, heat or cold application.

Improves circulation, reduces muscle tension and anxiety associated with pain. Enhances sense of well-being.

7. Encourage use of  relaxation techniques; e.g., deep breathing exercises, guided imagery, visualization, music.

Relieves muscle and emotional tension; enhances sense of  control and may improve coping abilities.

Dependent: 1. Administer  analgesics as ordered  by the physician.

The patient who is pain free will be better able to participate in care and take measures to  prevent complications.

 

Patient X Chief complaint: Difficulty of breathing Gender: Male Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wound Cues ( Subjective/

N   ursing Diagnosis

Age: 42 years old

Rationale

Goal of Care

Infections occur when an organism (e.g.,  bacterium, virus, fungus, or other   parasite) invades a susceptible host. Breaks in the integument, the body’s

After 24 hours of  nursing interventions the client will:

Nursing Intervention

Rationale

Evaluation

Objective) Objective: Post op status: Chest tube attached to the patient.

Risk for infection related to invasive  procedure

first line of defense, and/or the mucous membranes allow invasion by pathogens. If the host’s (patient’s) immune system cannot combat the invading organism adequately, an infection occurs. Open wounds,

1. Verbalize understanding of  individual causative or  risk factors.

Independent: 1. Note risk factors for  occurrence of  infection.

Intubation, prolonged After 24 hours of  mechanical ventilation, nursing care, patient trauma, general verbalized debilitation, understanding of the malnutrition, age, and  possible factors which invasive procedures are may contribute to factors that potentiate client’s risk of  acquiring infection and  prolonging recovery.

2. Identify at least two interventions to  prevent or reduce risk  of infection. 3. Demonstrate at least two techniques to  promote safe environment.

GOALS MET.

2. Reduce nosocomial risk factors via proper  hand washing or  alcohol-based hand rubs by all caregivers

Hand washing may be the simplest but the most important key to  prevent hospitalacquired infections.

traumatic or surgical, and patient as well. can be sites for  4. Be free of infection infection; soft tissues 3. Encourage deep as evidenced by (cells, fat, muscle) and  breathing, coughing temperature, blood organs (kidneys, lungs)  pressure within normal with frequent position can also be sites for  changes. limits and absence of  infection either after  complications (such as trauma, invasive redness and swelling at  procedures, or by incision site) invasion of pathogens

Maximizes lung expansion and mobilization of  secretions to prevent or  reduce atelectasis and accumulation of sticky, thick secretions.

carried through the  bloodstream or  lymphatic system.

Early recognition and treatment of infection enhances outcomes.

4. Monitor and report signs and symptoms of  infection: fever,

infection. In addition, patient’s vital signs are within normal range and no sign of infection was noted.

 

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increased respiratory rate. 5. Check all tubing for  Microorganisms may kinds, breaks or broken infiltrate if there is any connections. Verify  breaks in the that all connections are securely taped.

connection.

6. Verify that the drainage system is  below level of patient’s chest at all times.

This allows proper  drainage of pleural fluid.

7. Instruct client / significant others to

Protecting the integrity of the skin helps

 protect the integrity of  skin/insertion sites.

 prevent infection at the incision site.

Dependent:

 

1. Administer  antibiotics as needed.

Administering antibiotics helps treat microorganisms that are suspected to cause infection and/or  complications to the  patient.

 

Patient X Chief complaint: Difficulty of breathing Gender: Male Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wound Cues ( Subjective/

Age: 42 years old

N   ursing Diagnosis

Rationale

Goal of Care

Impaired physical mobility related to discomfort at surgical site

The incision site after  chest tube insertion is not closed for the tube to be detached. This might cause friction  between the surface of  the skin and the tube which might cause

After 2 days of nursing interventions, the client will:

discomfort and restrict movement. Source:

Nursing Intervention

Rationale

Evaluation

Objective) Subjective: “Diri ak nakakakiwa hin maupay kay nahadlok ak bangin matangal an tubo.” as verbalized by the  patient.

Independent 1. Determine degree of  mobility.

To assess functional ability.

2. Observe movement when client is unaware

To note any incongruencies with

treatment regimen and safety measures.

of observation.

reports of abilities.

2. Demonstrate techniques that enable resumption of  activities.

3. Support affected  body part.

1. Verbalize understanding of  situation or risk factors and individual

Objective: - inability to move or  change position when lying in bed - needs assistance when sitting down - demonstrates guarding behavior at surgical site

Understanding Medical-Surgical  Nursing 3 rd Edition by William, L. Hopper 

GOALS PARTIALLY MET.

3. Maintain skin integrity as evidenced

4. Perform range of  motion exercises,  passively at first then

 by absence of swelling, actively when the  patient is able. redness and pus formation at the 5. Assist patient to surgical site. ambulate as tolerated on first day as needed.

factors and also individual treatment. However, patient still To maintain position of  demonstrated limited function. activity and remains in  bed. This helps prevent contracture of the arm and the shoulder on the affected site. Ambulation helps maintain mobility and  prevents post operative complications.

Dependent: 1. Administer  medications prior to activity as needed.

After 2 days of nursing intervention, the patient verbalized understanding of the situation and risk 

To permit maximal effort and involvement in activity.

 

Patient X Chief complaint: Difficulty of breathing Gender: Male Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wound Cues ( Subjective/

N   ursing Diagnosis

Rationale

Goal of Care

Age: 42 years old

Nursing Intervention

Rationale

Evaluation

Objective) Objective: Post op status: Chest tube attached to the patient.

Risk for impaired skin integrity related to physical immobilization

Immobility, which leads to pressure, shear, and friction, is the factor most likely to put an individual at risk for  skin integrity. Advanced age; the

Within 3 hours of nursing interventions, the client will: 1. Verbalize understanding of  condition and causative factors.

normal loss of  elasticity; inadequate 2. Identify at least 2 interventions appropriate nutrition; for specific condition. environmental moisture, especially 3. Demonstrate from incontinence;  behaviors/lifestyle and vascular  changes to promote insufficiency  potentiate the effects healing and prevent complications/recurrence. of pressure and hasten the development of skin  breakdown.

4. Display progressive improvement in wound/lesion healing.

Independent: GOALS MET 1. Assess skin. Note color, turgor, circulation, and sensation.

Establishes comparative baseline  providing opportunity for timely intervention.

2. Maintain or instruct good

Maintaining clean, dry

skin hygiene.

skin provides a barrier  of infection.

3. Promote adequate fluid intake.

Helps maintain good circulating volume for  tissue perfusion.

4. Practice aseptic technique for  cleansing/dressing/medicating

Reduce risk for crosscontaminations.

lesions. 5. Change position frequently in bed and chair.

Improve circulation, muscle tone and  promotes client  participation.

6. Keep sheets and bedclothes clean, dry and free from wrinkles, crumbs and other 

Avoids friction/abrasion injury of skin.

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irritating materials.

After 3 hours of  nursing interventions, the client was able to verbalize understanding of  conditions, identified appropriate interventions, demonstrated and displayed behaviors to promote wound healing.

 

Dependent: 1. Administer nutritional supplements and vitamins as indicated.

Aids in healing/cellular  regeneration.

 

Patient X Chief complaint: Difficulty of breathing Gender: Male Diagnosis: Retained Hemothorax s/p CTT insertion right secondary to multiple stabbed wound

Cues ( Subjective/ Objective) Subjective: “Nayakan hi doc nga meada pa tubig ha ak   baga. Asya nakukurian ako pag ginhawa.”

Objective: - difficulty of   breathing - nasal flaring - ineffective cough

N   ursing Diagnosis

Rationale

Ineffective airway clearance related to retained secretions

 Normally the lungs are free from secretions. Due to the trauma that has occurred on the ribs, an intense inflammatory

Goal of Care Within 8 hours of nursing interventions, the client will:

Age: 42 years old

Nursing Intervention Independent:

 

1. Assess/monitor respiratory rate.

Tachypnea is usually  present to some degree and maybe pronounced during stress/concurrent acute infection. Respirations may be shallow and rapid with prolonged expiration in comparison to inspiration.

2. Note presence/degree of  dyspnea. Use 0-10 scale to rate breathing difficulty.

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Respiratory dysfunction is variable depending on the underlying process. Using a 0-10 scale to rate dyspnea aids in quantifying and tacking respiratory distress.

the permeable membrane of the  pleurae causing it to accumulate in the membranous space. Source:

Evaluation

GOAL MET.

1. Maintain airway  patency.

2. Verbalize response occurred. understanding of cause Exudation of  and therapeutic regimen.  plasma, leukocytes, and infiltration of  3. Demonstrate at least 2 most cells, growth  behaviors to improve or  factors and maintain clear airway. inflammatory leukocytes occurs in effect. These fluid and exudates crosses

Rationale

3. Assist client to assume  position of comfort; e.g. elevate head of bed, have client lean on overbed table or  sit on edge of bed.

Elevation of the head of the bed facilitates respiratory function by use of gravity; however, client in severe distress will seek the position that

Within 8 hours of  nursing interventions, patient was able to verbalized understanding of  regimen and demonstrated effective exercise. Airway patency is maintained.

 

most eases breathing. Supporting arms/legs with table, pillows, and so on helps reduce muscle fatigue and can aid chest expansion. 4. Encourage/assist with abdominal or pursed lip  breathing exercises.

Provides client with some means to cope with/control dyspnea and reduce airtrapping.

5. Encourage to increase fluid Hydration helps intake. Provide warm/tepid decrease the viscosity liquids. Recommend intake of  of secretions, fluids between instead of  during meals.

facilitating expectoration.