Water Seal drainage (WSD)

1. Bullow Drainage / WSD
   In thoracic trauma, WSD can mean:
   
   • Diagnostics:
     Determining the bleeding from a large or small blood vessels, so it can be determined necessary thoracotomy surgery or not, before the patient falls within shoks.
   
   
   • Therapy:
     Removing the accumulated blood or air in the pleural cavity. Returns the pleural cavity pressure so that the "mechanis of breathing" can go back as they should.
   
   
   • Preventive:
     Removing the air or blood into the pleural cavity so that the "mechanis of breathing" remains good.



2. WSD treatment and practice guidelines:
   
   • Prevent infection at the entry of the hose.
     Detecting the part where the entry of the hose, and replacement verband 2 days, and to note that gauze pads that cover the entry of hose and tube must not be soiled wiping the patient's body.
   
   
   • Reduce pain hose section entry. For severe pain will be given analgesics by the doctor.
     In the care that must be considered:
     • Determination of the hose.
       Hose set as comfortable as possible, so that the hose is inserted is not disturbed by patient movement, so that pain at the entry of the hose can be reduced.
     
     
     • Substitution position of the body.
       Try to keep the patient can feel good by putting a small pillow behind, or giving prisoners the hose, do abdominal breathing, change in body position while shifting weight, or put a pillow under the upper arm injuries.



3. Encourage the development of the lungs.
   
   • With WSD / Bullow drainage, is expected to inflate the lung.
     Breathing exercises.
   • Exercise an efficient cough: a cough with a sitting position, do not cough when the hose is clamped.
   • Control by physical examination and radiology.

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Nursing Assessment Nursing Care Plan for Pneumonia

Pneumonia

Pneumonia is an infection of one or both lungs which is usually caused by bacteria, viruses, or fungi. Prior to the discovery of antibiotics, one-third of all people who developed pneumonia subsequently died from the infection. Currently, over 3 million people develop pneumonia each year in the United States. Over a half a million of these people are admitted to a hospital for treatment. Although most of these people recover, approximately 5% will die from pneumonia. Pneumonia is the sixth leading cause of death in the United States.

Nursing Care Plan for Pneumonia

Nursing Assessment for Pneumonia

1. Health History :
   • A history of previous respiratory tract infection / cough, runny nose, takhipnea, fever.
   • Anorexia, difficulty swallowing, vomiting.
   • History of disease associated with immunity, such as; morbili, pertussis, malnutrition, immunosuppression.
   • Other family members who suffered respiratory illness.
   • Productive cough, breathing nostrils, rapid and shallow breathing, restlessness, cyanosis.
   
   
2. Physical Examination :
   • Fever, takhipnea, cyanosis, nostrils.
   • Auscultation of lung: wet ronchi, stridor.
   • Laboratory: leukocytosis, AGD abnormal, the LED increases.
   • Chest X-rays: abnormal (scattered patches of consolidation in both lungs).
   
   
3. Psychosocial Factors :
   • Age, growth.
   • Tolerance / ability to understand the action.
   • Coping.
   • The experience of parting with the family / parents.
   • The experience of previous respiratory tract infections.
   
   
4. Family Knowledge, Psychosocial :
   • The level family knowledge about the disease bronchopneumonia.
   • Experience in dealing with the family of respiratory disease.
   • Readiness / willingness of families to learn to care for her child.
   • Family Coping
   • The level of anxiety.

http://free-nursingcareplan.blogspot.com/2011/06/nursing-care-plan-for-pneumonia.html

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Nursing Diagnosis of Empyema - Impaired Gas Exchange

Definition : Impaired Gas Exchange

Circumstances where an individual has decreased course of gas (O2 and CO2) that an actual or risk of lung alveoli and the vascular system.

Nursing diagnosis of empyema :

Impaired Gas Exchange related to airway obstruction secondary to the buildup of secretions, Bronchospasme

Nursing Intervention and Rational:

Assess the frequency and depth of breathing, note the use of auxiliary respiratory muscles and an inability to speak due to shortness
R /: Evaluation of the degree of respiratory distress or failure and chronic disease processes.

Help clients to find a position that facilitates breathing, with the head higher
R /: Supply of oxygen can be updated, in order to practice breathing lungs do not collapse.

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ABCDE Nursing Care Plan for COPD

COPD, or chronic obstructive pulmonary disease, is a progressive disease that makes it hard to breathe. "Progressive" means the disease gets worse over time.

COPD can cause coughing that produces large amounts of mucus (a slimy substance), wheezing, shortness of breath, chest tightness, and other symptoms.

Cigarette smoking is the leading cause of COPD. Most people who have COPDsmoke or used to smoke. Long-term exposure to other lung irritants, such as air pollution, chemical fumes, or dust, also may contribute to COPD.

nhlbi.nih.gov

Assessment

Airway

• Assess and maintain airway
• Do the head tilt, chin lift if necessary
• Use the help of the airway if necessary
• Consider to be referring to the anesthesiologist

Breathing

• Assess oxygen saturation using pulse oximeter
• Do inspection arterial blood gases to assess pH, PaCO2 and PaO2
• If the arterial pH less than 7.2, more profitable patients using non-invasive ventilation (NIV) and references must be made in accordance with local policy
• Control of oxygen therapy to maintain oxygen saturation over 92%
• Strictly monitoring PaCO2
• Record the temperature
• Make checks for signs of:
  • cyanosis
  • clubbing
  • pursed lip breathing
  • movement symmetry
  • intercostal retractions
  • tracheal deviation
• Listen to the:
  • wheezing
  • crackles
  • decrease in airflow
  • silent chest
• Make checks to see piston :
  • pneumothorax
  • consolidation
  • signs of heart failure
• If there is evidence of an infection usually caused by bacterial pathogens including :
  • streptococcus pneumoniae
  • haemophilus influenzae
  • moraxella catarrhalis

Circulation

• assess heart rate and rhythm
• record blood pressure
• check ECG
• do intake output, and do a complete blood
• pairing IV access
• fluid restriction did

Disability

• Assess the level of consciousness by using AVPU
• Patients showed a decrease in consciousness needed medical help immediately and treated in ICU.

Exposure

• If the patient is stable and health history examinations do other physical examination.

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