Question

Nursing careplan of Pneumothorax

Answer 1

Pneumothorax: It s a condition in which lung collapse due to the leakage of air into the space between the lungs and chest wall.

Nursing care plan:

1. Acute pain related to positive pressure in the pleural space.

Goals: Patient experiences reduced pain and uses appropriate diversional activities and relaxation techniques.

Nursing interventions for pain:

(a). Assessment of pain for its location, character, onset,duration, quality and severity- to plan optimal care based on patient problem.

(b). Assess about previous history of pain and control measures followed.

(c). Identify patient's perception of pain- helps to understand what the patient is feeling exactly.

(d). Assess status of pain frequently like vital signs - considering pain as fifth vital signs helps to know patient pain level frequently.

(e). Nurse should initiate pain assessment as the client may not reveal feeling of pain unless it is asked.

(f). Assess patient's readiness to learn relaxation techniques and exercises as a pain relief measure.

2. Ineffective breathing pattern related to respiratory distress.

Goals: Patient experiences effective breathing pattern as evidenced by relaxed breathing with normal rate amd depth.

Interventions:

(a). Proper positioning of the patient to ensure optimal breathing pattern like Fowler's position.

(b). Encourage and demonstrate deep breathing exercises like use of spirometer and breathing techniques.

(c). Encourage diaphragmatic breathing to ensure relaxation of muscles and patient's oxygen level.

(d). Provide oxygen and respiratory medicine as per doctors order

(e) Encourage patient about proper coughing and breathing techniques.

(f). Encourage small and frequent meals to prevent crowding of diaphragm.

3. Ineffective peripheral tissue perfusion related to severe hypoxemia.

Goals: Patient will experience maximum tissue perfusion as evidenced by warm and dry skin, strong peripheral pulses, vital signs within normal limits.

Interventions:

(a). Assess the patient for decreased tissue perfusion to get a baseline characteristics.

(b). Assess for possible contributing factors for impaired tissue perfusion as early detection of causes helps in effective management.

(c). Review laboratory datas including ABG results, electrolyte, coagulation level.

(d). Proper mental status examination as impaired perfusion causes altered mental status.

(e). Ensure optimal fluid balance as adequate fluid balance ensures proper filling pressure and optimal cardiac output

(f). Assist the patient with position change

(g) Encourage active and passive ROM exercises as it prevents further circulatory compromise.

(h). Administer oxygen and medication as per order.

4 .Anxiety related to breathing difficulty.

Goals:

Interventions:

(a). Assess for the patient anxiety level and contributing factors to plan effective care

(b). Observe patient's utilisation of coping techniques and defense mechanisms to cope wth anxiety

(c). Introduce the new environment to the patient as awareness about new environment promotes comfort and decreased anxiety to the patient.

(d). Interact with patient in a calm and quiet manner

(e) Accept patient's feeling,do not argue or debate with patients.

(f). Use simple language and avoid using complicated statement to maintain patient attention.

(g) Allow the patient to talk about exact feeling and anxiety provoking situations if any as it helps to plan effective relaxation techniques.

(h) Indroduce effective problem solving methods to the patient and encourage relaxation techniques.