Thursday, November 1, 2012

Impaired Gas Exchange - Pleural Effusion

Nursing Diagnosis for Pleural Effusion : Impaired Gas Exchange related to changes in capillary membrane - alveolar

Purpose:
  • Breathing the air in the balance between the concentration of arterial blood
The expected outcomes:
  • Showed an increase in ventilation and oxygen sufficient
  • Analysis of blood gases within normal limits.
Nursing Interventions:

Airway Management
  • Clear the airway
  • Encourage breathing long and lasting cough
  • Set the appropriate humidity
  • Set the position to reduce dyspnoea
  • Monitor frequency of breath associated with oxygen adjustment
Respiration Monitor
  • Monitor rate, rhythm, depth and effort to breathe
  • Note the movement of the chest, breast symmetry, using tools and intercostal muscle retraction
  • Monitoring nasal breathing, the snoring
  • Monitor breathing patterns, bradipneu, takipneu, hyperventilation, resirasi kusmaul, etc.
  • Palpation similarity lung expansion
  • Anterior and posterior chest percussion of both lungs
  • Monitor the diaphragm muscle fatigue
  • Auscultation breath sounds, record or ketidakadanya area reduction and ventilation and breath sounds
  • Monitor restlessness, anxiety and anger
  • Note the characteristic cough and duration
  • Monitor respiratory secretions
  • Dyspnoea and monitor the development and progression of events
  • Perform maintenance nebulized therapy if necessary
  • Place the patient laterally to prevent aspiration
Management Asid Base
  • Send a laboratory examination of acid-base balance (eg, blood gas analysis, urine and serum levels)
  • Monitor blood gas analyzer for low PH
  • Position the patient for optimum ventilation perfusion
  • Maintain the cleanliness of the air (suction and chest therapy)
  • Monitor respiration pattern
  • Monitor work pernafsan (respiratory rate).

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