Cardiac Tamponade Nursing Care Plan

 

Nursing Diagnosis

• Ineffective Breathing Pattern

Related to

• hyperventilation

Characterized by:

tachypnea, signs kussmaul breathing.

Goal

• Patterns breath back effectively.

Expected outcomes

• Tachypnea no
• Signs kussmaul no
• Vital signs are within normal ranges (RR: 16-20 X / min).

Nursing Interventions

Independent

• Monitor strictly vital signs, especially respiratory frequency.
  • Rationale: Changes in breathing patterns can affect vital signs.
• Monitor the contents breathing, chest expansion, regularity of breathing, mouth breathing and muscle use a respirator.
  • Rationale: The development of the chest and use accessory muscles indicate breathing pattern disorders.
• Give the semi-Fowler position if not contraindicated.
  • Rationale: Facilitates lung expansion
• Teach clients a deep breath.
  • Rationale: With the deep breathing exercise can increase oxygen intake.

Collaborative

• Give oxygen as indicated.
  • Rationale: Oxygen adequate to avoid the risk of tissue damage.
• Give medication as indicated.
  • Rationale: Medications that can affect the respiratory ventilation.