NURSING DIAGNOSIS: Breathing Pattern, risk for ineffective

Risk factors may include

• Intra-abdominal fluid collection (ascites)
• Decreased lung expansion, accumulated secretions
• Decreased energy, fatigue

Desired Outcomes

• Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.

Nursing Interventions & Rationale

Ineffective Breathing Pattern — Liver Cirrhosis Nursing Care Plans Original source at: Nurseslabs

NURSING DIAGNOSIS: Breathing Pattern, ineffective

May be related to

• Pain
• Muscular impairment
• Decreased energy/fatigue

Possibly evidenced by

• Tachypnea; respiratory depth changes, reduced vital capacity
• Holding breath; reluctance to cough

Desired Outcomes

• Establish effective breathing pattern.
• Experience no signs of respiratory compromise/complications.

Ineffective Breathing Pattern — Cholecystectomy Nursing Care Plans Original source at: Nurseslabs

A cholecystectomy consists of excising the gallbladder from the posterior liver wall and ligating the cystic duct, vein, and artery. The surgeon usually approaches the gallbladder through a right upper paramedian or upper midline incision if necessary, the common duct may be explored through this incision. When stones are suspected in the common duct, operative cholangiography may be performed (if it has not been ordered preoperatively). The surgeon may dilate the common duct if it is already dilated as a result of a pathologic process. Dilation facilitates stone removal. The surgeon passes a thin instrument into the duct to collect the stones, either whole or after crushing them.

After exploring the common duct, the surgeon usually inserts a T0tube to ensure adequate bile drainage during duct healing (choledochostomy). The T-tube also provides a route for postoperative cholangiography or stone dissolution, when appropriate.

A conventional open cholecystectomy is indicated when a laparoscopic cholecystectomy does not allow for retrieval of a stone in the common bile duct and when the client’s physique does not allow access to the gallbladder. Occasionally, when a client is very obese, the gallbladder is not retrievable via laparoscopic instruments. Further, a surgeon may have difficulty accessing the gallbladder in an adult with a small frame and may need to perform the conventional open cholecystectomy.

Below we have 8 Cholecystectomy Nursing Care Plans

1 Preoperative Problem: Acute Pain

The flow of bile in the gall bladder is obstructed due to the presence of stones. When the bladder releases bile, it contracts and there is spasm, thus it cannot adequately release bile due to the stone, it stimulates the release of cytokines resulting to pain.

2 Preoperative Problem: Fear

Undergoing open cholecystectomy, the patient may perceive threat like the outcome of the surgery that is consciously recognized by the client as danger

3 Ineffective Breathing Pattern

Respirations may be increased as a result of pain or as an initial compensatory mechanism. however, increased work of breathing may indicate increasing oxygen consumption and energy expenditures and/or reduced respiratory reserve.

4 Risk for Aspiration

Prior to any surgical invasion, general anesthesia is induced. It relaxes the muscles of the body and depresses the sensation of pain, thus the gag and swallowing reflex is temporarily suppressed that may lead to aspiration.

5 Post Operative Acute Pain

In performing cholecystectomy, surgical incision is done. By which, the incision causes direct irritation to the nerve endings by chemical mediators released at the site such as bradykinin. This irritation will send signal to the cortex and thalamus of the brain thus producing pain perception.

6 Activity Intolerance

Post-op pt. usually is under bed rest for few days that may hinder them to their usual activity. Presence of surgical incision procedures causes the pt. to be reluctant in doing personal activities, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation.

7 Impaired Physical Mobility

Presence of surgical incision procedures causes the pt. to be reluctant in doing movements such as ROM, because those may result in the stimulation of the nerve endings, during movement, thus, increase pain sensation.

8 Risk for Infection

The patient is at risk of acquiring infection due to the break in the continuity of the first line defense which is the skin. The patient shall have undergone cholecystectomy, thus there is an incision and suture made in the abdomen. If there is a breakage in the skin, the pathogens will easily invade the body’s system thus increasing risk for infection.

8 Cholecystectomy Nursing Care Plans Original source at: Nurseslabs

Bronchial asthma

What do you think is the nursing goal for patient’s with bronchial asthma, and what is that one-most nursing diagnosis that pops to your head when you hear asthma?

This post contains 5 bronchial asthma nursing care plans. 

1. Ineffective Airway Clearance - Bronchial Asthma Nursing Care Plans

The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstriction, increased vascular permeability leading to fluid leakage from the lung vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance.

Asthma- Ineffective- Airway- Clearance

5 Bronchial Asthma Nursing Care Plans Original source at: Nurseslabs

• An increase in the size and number of submucous glands in the large bronchi which causes increase mucus production
• An increased number of globlet cells, which also secrete mucus
• Impaired ciliary function, which reduces mucus clearance

1. Ineffective Airway Clearance

COPD is an inflammatory response to the offending microorganism. The defense mechanisms of the lungs lose effectiveness and allow organisms to penetrate the sterile respiratory tract, as a result inflammation develops. The inflammation and increased secretions make it difficult to maintain a patent airway.

2 Ineffective Breathing Pattern RT Retained Secretions

The presence of microorganisms in the lungs causes body to increase the secretory activity of goblet cells to get rid of the invading organism but the mechanism is not enough which allows the stasis of mucus secretion leading to ineffective breathing pattern.

3. Impaired Gas Exchange RT Altered Oxygen Balance

The disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection leading to inflammation and accumulation of secretions. Inflamed and fluid-filled alveolar sacs cannot exchange oxygen and carbon dioxide effectively.

4. Sleep Pattern Disturbance RT Difficulty of Breathing

COPD patients need a comfortable position such as the High-Fowler’s position during sleeping in order to promote lung expansion. Lying flat on bed promotes the occurrence of DOB and makes the patient uncomfortable due to the impaired alveolar ventilation which the body processes at night can’t be controlled

5. Risk for Spread of Infection RT Stasis of Secrections & Decreased Ciliary Action

Once the bacteria, virus, or fungus enter the lungs, they usually settle in the air sacs of the lung where they rapidly grow in number. This area of the lung then becomes filled with fluid and pus as the body attempts to fight the infection. Disruption of the mechanical defenses of cough and ciliary motility leads to colonization of the lungs and subsequent infection

Other nursing diagnoses:

• 6 High risk for suffocation
• 7 High risk for aspiration
• 8 Anxiety RT acute breathing difficulties
• 9 Activity Intolerance RT inadequate oxygenation
• 10 Imbalanced Nutrition: Less than body requirements RT reduced appetite and dyspnea (for empysema)

10 Chronic Obstructive Pulmonary Disease: Bronchitis Nursing Care Plans Original source at: Nurseslabs

Because heart failure causes vascular congestion, it is often called congestive heart failure, although most cardiac specialist no longer use this term. Other terms used to denote heart failure include chronic heart failure, cardiac decompensation, cardiac insufficiency and ventricular failure (Joyce M. Black, 2008).

Here are 10 Congestive Heart Failure Nursing Care Plans

1. Decreased Cardiac Output - Congestive Heart Failure Nursing Care Plans

The heart fails to pump enough blood to meet the metabolic needs of the body. The blood flow that supplies the heart is also decreased thus decrease in cardiac output occurs, blood then is insufficient and making it difficult to circulate the blood to all parts of the body thus may cause altered heart rate and rhythm, weakness and paleness

NDx: Decreased cardiac output r/t altered heart rate and rhythm AEB bradycardia

10 Congestive Heart Failure Nursing Care Plans Original source at: Nurseslabs

The nursing goal for a patient who underwent mastectomy can be: pain management, counseling due to disturbed body image, and preventing infection due to surgical incision.

This post contains 14 nursing care plans for patients who underwent mastectomy.

1. Risk for Injury - Mastectomy Nursing Care Plans

Areas involving the neck are considered to be the most vascularized parts of a person’s body. We all know that the most common complication of a surgery is excessive bleeding or hemorrhage, this was brought about by excessive blood loss intra or post operatively.

NDx: Risk for Injury related to change in center of gravity secondary to extensive removal of chest tissue

14 Mastectomy Nursing Care Plans Original source at: Nurseslabs

I. Pathophysiology

• Partial or complete collapse of lung due to accumulation of air (pneumothorax), blood (hemothorax), or other fluid (pleural effusion) in the pleural space
• Intrathoracic pressure changes induced by increased pleural space volumes and reduced lung capacity, causing respiratory distress and gas exchange problems and producing tension on mediastinal structures that can impede cardiac and systemic circulation
• Complications include hypoxemia, respiratory failure, and cardiac arrest.

II. Classification

• Primary spontaneous pneumothorax
• Secondary spontaneous pneumothorax
• Iatrogenic pneumothorax
• Traumatic pneumothorax

III. Etiology

• Primary spontaneous: rupture of pleural blebs typically occurs in young people without parenchymal lung disease or occurs in the absence of traumatic injury to the chest or lungs
• Secondary spontaneous: occurs in the presence of lung disease, primarily emphysema, but can also occur with tuberculosis (TB), sarcoidosis, cystic fibrosis, malignancy, and pulmonary fibrosis
• Iatrogenic: complication of medical or surgical procedures, such as therapeutic thoracentesis, tracheostomy, pleural biopsy, central venous catheter insertion, positive pressure mechanical ventilation, inadvertent intubation of right mainstem bronchus
• Traumatic: most common form of pneumothorax and hemothorax, caused by open or closed chest trauma related to blunt or penetrating injuries

IV. Statistics

(American Lung Association, June 2005)

• Morbidity: Primary spontaneous pneumothorax affects 9,000 persons per year and is more common in tall, thin  men between 20 and 40 years of age.
• Recurrence rate: Is about 40% for both primary and secondary spontaneous pneumothorax, occurring in intervals of 1.5 to 2 years.
• Mortality: Rate is 15% for those with secondary pneumothorax.

Care Setting

Client is treated in inpatient medical or surgical unit.

Nursing Priorities

1. Promote or maintain lung reexpansion for adequate oxygenation and ventilation.
2. Minimize or prevent complications.
3. Reduce discomfort and pain.
4. Provide information about disease process, treatment regimen, and prognosis.

Discharge Goals

1. Adequate ventilation and oxygenation maintained.
2. Complications prevented or resolved.
3. Pain absent or controlled.
4. Disease process, prognosis, and therapy needs understood.
5. Plan in place to meet needs after discharge.

NURSING DIAGNOSIS: Ineffective Breathing Pattern

May be related to

• Decreased lung expansion due to air or fluid accumulation
• Musculoskeletal impairment
• Pain and anxiety
• Inflammatory process
• Possibly evidenced by
• Dyspnea, tachypnea
• Changes in depth or equality of respirations; altered chest excursion
• Use of accessory muscles, nasal flaring
• Cyanosis, abnormal ABGs

Desired Outcomes/Evaluation Criteria—Client Will

Respiratory Status: Ventilation

• Establish a normal and effective respiratory pattern with ABGs within client’s normal range.
• Be free of cyanosis and other signs or symptoms of hypoxia.

Actions/Interventions

Respiratory Monitoring

Independent

• Identify etiology or precipitating factors, such as spontaneous collapse, trauma, malignancy, infection, and complication of mechanical ventilation.
• Evaluate respiratory function, noting rapid or shallow respirations, dyspnea, reports of “air hunger,” development of cyanosis, and changes in vital signs.
• Monitor for synchronous respiratory pattern when using mechanical ventilator. Note changes in airway pressures.
• Auscultate breath sounds.
• Note chest excursion and position of trachea.
• Assess fremitus.
• Ventilation Assistance
• Assist client with splinting painful area when coughing, or during deep breathing.
• Maintain position of comfort, usually with head of bed elevated. Turn to affected side. Encourage client to sit up as much as possible.
• Maintain a calm attitude, assisting client to “take control” by using slower, deeper respirations.

Tube Care: Chest

• Once chest tube is inserted:
• Determine if dry seal chest drain or water seal system is used.
• If water seal system is used:
  • Check suction control chamber for correct amount of suction, as determined by water level, wall or table regulator, at correct setting.
  • Check fluid level in water-seal chamber; maintain at prescribed level.
  • Observe for bubbling in water-seal chamber.
  • Evaluate for abnormal or continuous water-seal chamber bubbling.
  • Determine location of air leak (client or system centered) by clamping thoracic catheter just distal to exit from chest.
  • Place petrolatum gauze or other appropriate material around the insertion as indicated.
  • Clamp tubing in stepwise fashion downward toward drainage unit if air leak continues.
  • Seal drainage tubing connection sites securely with lengthwise tape or bands according to established policy.
  • Monitor water-seal chamber “tidaling.” Note whether change is transient or permanent.
  • Position drainage system tubing for optimal function; for example, shorten tubing or coil extra tubing on bed, making sure tubing is not kinked or hanging below entrance to drainage container. Drain accumulated fluid as necessary.
  • Note character and amount of chest tube drainage, whether tube is warm and full of blood and whether bloody fluid level in water-seal bottle is rising.
  • Evaluate need for gentle “milking” of chest tube per protocol. If thoracic catheter is disconnected or dislodged:
    • Observe for signs of respiratory distress. If possible, reconnect thoracic catheter to tubing and suction, using clean technique. If the catheter is dislodged from the chest, cover insertion site immediately with petrolatum dressing and apply firm pressure. Notify physician at once.
  • After thoracic catheter is removed:
    • Cover insertion site with sterile occlusive dressing. Observe for signs or symptoms that may indicate recurrence of pneumothorax, such as shortness of breath and reports of pain. Inspect insertion site, noting character of drainage.

Collaborative

• Assist with and prepare for reinflation procedures; for example, simple aspiration, Heimlich valve, and chest tube placement with chest tube drainage unit (CDU).
• Obtain postplacement x-rays and review serial chest x-rays.

Ventilation Assistance

• Monitor and graph serial ABGs and pulse oximetry. Review vital capacity and tidal volume measurements.
• Administer supplemental oxygen via cannula, mask, or mechanical ventilation, as indicated.
• Administer analgesics and sedatives, as indicated.

Ineffective Breathing Pattern — Pneumothorax Nursing Care Plan Original source at: Nurseslabs

Pneumonia

Incidences of Pneumonia

Pneumonia is a common illness in all parts of the world in all age groups. Majority of deaths occur in the newborn period in children, with over two million deaths a year worldwide.

• The World Health Organization estimates that one out of three newborn infant deaths is due to pneumonia.
• It kills more children than any other illness, accounting for 19% of all under-five deaths.
• According to the National Statistical Coordination Board of the Philippines, there are 776,562 of pneumonia in the country in 2004 alone. This could be an implication that pneumonia is one of the leading causes of morbidity and mortality in the country.
• World Health Organization notes Invasive Pneumococcal Disease deaths at 1.6 million people each year.
• Of these, 700,000 to one million are children under five years old and over 90 percent of these deaths occur in developing countries.
• Pneumonia is a top killer in India,China,Nigeria,Pakistan,Bangladesh,Indonesia, and Brazil.

Additional & Updated Nursing Care Plans for Pneumonia

• Deficient Knowledge — Pneumonia Nursing Care Plans
• Risk for Deficient Fluid Volume — Pneumonia Nursing Care Plans
• Imbalanced Nutrition — Pneumonia Nursing Care Plans
• Acute Pain — Pneumonia Nursing Care Plans
• Activity Intolerance — Pneumonia Nursing Care Plans
• Risk for Infection — Pneumonia Nursing Care Plans
• Impaired Gas Exchange — Pneumonia Nursing Care Plans
• Ineffective Airway Clearance — Pneumonia Nursing Care Plans

1. Ineffective Airway Clearance

NDx: Ineffective airway clearance related to presence of secretions secondary to pneumonia.

The inflammation and increased secretions make it difficult to maintain a patent airway, which is cause by decrease ability to expel the excessive mucus produced that will lead to extensive obstruction of the airway.

5 Pneumonia Nursing Care Plans Original source at: Nurseslabs

Pleural fluid normally seeps continually into the pleural space from the capillaries lining the parietal pleura and is reabsorbed by the visceral pleural capillaries and lymphatic system. Any condition that interferes with either secretion or drainage of this fluid leads to pleural effusion.

Causes of pleural effusion can be grouped into four major categories:

• Increased systemic hydrostatic pressure (e.g., heart failure)
• Reduced capillary oncotic pressure (e.g., liver or renal failure)
• Increased capillary permeability (e.g., infection or trauma)
• Impaired lymphatic function (e.g., lymphatic obstruction caused by tumor)

1. Ineffective Breathing Pattern - Pleural Effusion Nursing Care Plans

NDx: Ineffective Breathing Pattern RT Decreased Lung Volume Capacity as evidenced by tachypnea, presence of crackles on both lung fields and dyspnea

Ineffective breathing pattern occurs when inspiration and expiration does not provide adequate ventilation. Pleural inflammation causes sharp localized pain that increases deep of breathing, coughing and movement. This can result to shallow and rapid breathing pattern. Distal airways and alveoli may not expand optimally with each breath, increasing the possibility of atelectasis and impaired gas exchange.

6 Pleural Effusion Nursing Care Plans Original source at: Nurseslabs