Ineffective Breathing Pattern related to Cardiac Tamponade

Nursing Care Plan for Cardiac Tamponade

Nursing Diagnosis and Interventions for Cardiac Tamponade : Ineffective Breathing Pattern

Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium).

Symptoms
  • Anxiety, restlessness
  • Chest pain
    • Radiating to the neck, shoulder, back, or abdomen
    • Sharp, stabbing
    • Worsened by deep breathing or coughing
  • Difficulty breathing
  • Discomfort, sometimes relieved by sitting upright or leaning forward
  • Fainting, light-headedness
  • Pale, gray, or blue skin
  • Palpitations
  • Rapid breathing
  • Swelling of the abdomen or other areas
Other symptoms that may occur with this disorder:
  • Dizziness
  • Drowsiness
  • Weak or absent pulse

Nursing Diagnosis for Cardiac Tamponade : Ineffective Breathing Pattern
related to: hyperventilation
characterized by: tachypnea, signs kussmaul breathing.

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

Nursing Interventions: Ineffective Breathing Pattern - Nursing Care Plan for Cardiac Tamponade

Independent:
  1. Monitor strictly vital signs, especially respiratory frequency. Rationale: Changes in breathing patterns can affect vital signs.
  2. 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.
  3. Give the semi-Fowler position if not contraindicated. Rationale: Facilitates lung expansion
  4. Teach clients a deep breath. Rationale: With the deep breathing exercise can increase oxygen intake.

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