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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