Empyema
Empyema is a collection of pus in the space between the lung and the inner surface of the chest wall (pleural space).
Symptoms
- Chest pain, which worsens when you breathe in deeply (pleurisy)
- Dry cough
- Excessive sweating, especially night sweats
- Fever and chills
- General discomfort, uneasiness, or ill feeling (malaise)
- Shortness of breath
- Weight loss (unintentional)
Nursing Diagnosis of Empyema 1:
Ineffective airway clearance related to bronchus spsame, increased production of secretions, weakness
Nursing Intervention and Rational:
Auscultation of breath sounds: note the presence of breath sounds, assess and monitor breathing sounds
R /: To determine the presence of airway obstruction, the degree yan tachipneu found the process of acute infection.
Assess the frequency of respiratory
R /: The process of acute infection (tachipnea)
Nursing diagnosis of empyema 2:
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.
Nursing diagnosis of empyema 3:
Imbalanced Nutrition, Less Than Body Requirements related to Shortness of breath, anorexia, nausea, vomiting, drug effects, weakness
Nursing Intervention and Rational:
Obserasi intake and output / 8 hours. The amount of food consumed each day and measuring body weight each day
R /: Identifying the lack of progress / storage of the expected goal
Create a fun atmosphere, an environment free of odor during meal times:
Imbalanced Nutrition, Less Than Body Requirements related to Shortness of breath, anorexia, nausea, vomiting, drug effects, weakness
Nursing Intervention and Rational:
Obserasi intake and output / 8 hours. The amount of food consumed each day and measuring body weight each day
R /: Identifying the lack of progress / storage of the expected goal
Create a fun atmosphere, an environment free of odor during meal times:
- Perform mouth care before and after meals
- Clean environment in which the presentation of food
- Avoid use of foul-smelling fragrances
- Perform chest physiotherapy and nebulizer at least one hour before meals
- Provide a place to dispose of tissues / secretions cough
