Cardiac Tamponade Nursing Care Plan


Nursing Diagnosis
  • Ineffective Breathing Pattern
Related to
  • hyperventilation

Characterized by:

tachypnea, signs kussmaul breathing.

  • Patterns breath back effectively.
Expected outcomes
  • Tachypnea no
  • Signs kussmaul no
  • Vital signs are within normal ranges (RR: 16-20 X / min).
Nursing Interventions
  • 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.
  • 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.