ients to prevent development of atelectasis and pneumonia. Tucker , p. 304Pt demonstrated correct use and knowledge of incentive spirometer. Pt. Did so by placing mouth piece between teeth, closing the lips around the mouth piece, inhaling through mouth only, and taking a slow deep breaths. Pt held breath for 3-5 seconds Pt. remove mouth piece and exhale slowly. ( Procedure from Tucker p. 328)Monitoring chest tube 6. Check suction control chamber for correct amount of suction (by water level, wall regulator at correct setting) Maintains prescribed intrapleural negativity, which promotes optimum lung expansion and/or fluid drainage. Doenges, p. 198Chest tube to wall seal set at 20cm with continuous suction of 50 -60 mm Hg. All tubes patent with no signs of leakage ( air or fluid) around seals.NDX #1. Con’t Intervention /Action RationalesEvaluation / Outcome Criteria7. Check fluid level in water-seal chamber / bottle; maintain at prescribed level Water in a sealed chamber serves as a barrier that prevents atmospheric air from entering the pleural space should the suction source be disconnected and aids in evaluating whether the chest drainage system is functioning appropriately. Sufficient water in bottle 1/2 full to provide barrier. OUTCOME/GOAL STATEMENT: Short Term Goal: Pt. Will maintain an effective breathing pattern as evidenced by the following: normal rate, rhythm, and depth of respirations. Long Term goal: Pt. Will ABG’s Blood gases within normal range. Doenges, p. 197 & Tucker , p. 304#2. NURSING DIAGNOSIS: Ineffective Airway Clearance R/T decreased flexibility of lung tissue AEB fungal infection of lungs, chest tube, fluid presence . Doenges, p. 164Intervention /ActionRationalesEvaluation / Outcome Criteria1. Assess rate / depth of respirations and chest move- ment, Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/o...
