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.