Care Plan Neumothorax

Nursing Care Plan
Name of
client:
Ward: AED
Nursing diagnosis

Age/Sex:

Medical diagnosis: right spontaneous pneumothorax
Ineffective breathing pattern related to accumulation of fluid in pleural cavity secondary to right spontaneous
pneumothorax as evidenced by high RR and mild dyspnea

Goal & Expected
Outcome
Subjective data:
Goal:
Attend AED becaused Patient respiration rate
of with acute shortness within normal range (12of breath
20/min) within a week
Nursing Assessment

Objective data:
-SpO2 was 93%
-RR 28/min
-used accessory
respiratory muscle
to breath

Hospital number:

Expected outcomes
(EO):
1. Demonstrate a
breathing pattern that
supports patient’s
blood gas exchange
within patient’s
normal parameters.
2. Patient’s respiratory
rate will be in normal
range (12-20/min).

3. avoid specific factors
that leads to
ineffective breathing
patterns

Interventions
1. Monitor patient’s pulse rate 1.
and respiratory rate. Access
patient’s respiratory rate
and depth by observation
and pulmonary function
test and note any
abnormalities.
2.

2. Monitor patient’s oxygen
saturation in arterial blood.
3.

3. Monitor chest tube
drainage system
4. Teach and encourage
patient to use different
methods of breathing (i.e.
pursed-lip breathing and
diaphragmatic breathing)

Outcome
Evaluation
This is to monitor patient’s
1. Evaluate patient’s
condition and ensure that his
oxygen saturation,
condition will not deteriorate. If
pulse rate and
he does, this may imply that there
respiratory rate
are other underlying factors that
every 4h and
contribute to his condition.
document it on
T.P.R. and B.P.
An oxygen saturation of less than
chart.
99% may cause hypoventilation
2. Evaluate patient’s
understanding of
Maintains prescribed intrapleural
the appropriate
negativity, which promotes
breathing and
optimum lung expansion and fluid
coughing
drainage.
techniques by
asking the patient to...