uid volume deficit R/T insufficient intake AEB low intake of PO fluids. (Potential) 9.High risk for diarrhea R/T meds AEB loose stools. (Potential)10.Sleep pattern disturbance R/T pain and hospital routine AEB clients c/o being awakened q 2 hrs. (Actual) #1. NURSING DIAGNOSIS: Ineffective breathing pattern related to decreased lung expansion secondary to pus in the pleura space AEB asymmetrical chest expansion and decreased breath sounds over affected area. (Combination of Doenges p.197 and Tucker p.304 Patient Care Standard for Thoracic Empyema)Intervention /ActionRationalesEvaluation / Outcome Criteria1. Assess chest movement, noting signs of asymmetrySigns of asymmetry may indicate pus or fluid in pleural cavity. Tucker p.304Pt. Showed greater expansion of chest on left side ( opposite tube insertion)2. Auscultate breath sounds q2h to 4h for adventitious or decreased soundsBreath sounds may be diminished or absent in a lobe, lung segment, or entire lung field (unilateral). Atelectatic area will have no breath sounds, and partially collapsed lapsed areas have decreased sounds. Doenges, p. 197Breath sounds distinctly less on left side near tube insertion point3. Monitor BP, T, R, and apical pulse q2h to 4h to assess for infective processChange in values from baseline for pt)may indicate infection starting . i.e. sustained increase in temp. Tucker , p. 304BP 114/55, P 84, T 97.4, R 244. Administer oxygen per nasal cannula at 2 to 6 L / min as ordered unless contraindicated to treat hypoxia. Place patient in a sitting position with head of bed elevated 60 to 90 degrees to maximize breathingPromotes maximal inspiration; enhances lung expansion and ventilation in unaffected side. Doenges, p. 197 & Tucker , p. 304Pt. Stated that he breaths easier with O2 and HOB in 60 degree position.5. Encourage use of incentive spirometer. RationaleTo assist Pt . maintaining maximal inspiratory effort; effective when used by post operative pat...
