Nursing Care

Topics: Nursing, Nursing care plan, Surgery Pages: 3 (568 words) Published: January 29, 2014


NURSING PROCESS
WORKSHEETS

Client Name:

NURSING PROCESS

Nursing Diagnoses: (include 1 psychosocial)

1. Impaired Gas Exchange related to thoracotomy as evidenced by O2 via NC, L side chest tube, Hx of asthma, Obesity, chest x-ray showing congestion and atelectasis in the left lower lobe, and SOB on exertion.

2. Acute Pain related to surgical incision as evidenced by patients verbal report of pain (rated at a 10 on a scale from 1-10), positioning to avoid pain, elevated systolic blood pressure, facial grimace, decreased ambulation and movement to avoid pain.

3. Impaired Skin Integrity related to a thoracotomy procedure as evidenced by a L lateral incision post Thoracotomy for resection of mediastinal cyst and report of pain in the affected area.

4. Infection related to thoracotomy as evidenced by elevated WBC’s (17.8) and traumatized tissue from surgery.

5. Knowledge deficient related to lack of exposure of surgical procedure recovery as evidenced by patient’s statement, “I did know I would be in the hospital this long”.

Nursing Diagnosis # 1:
Impaired Gas Exchange related to thoracotomy as evidenced by O2 via NC, L side chest tube, Hx of asthma, Obesity, chest x-ray showing congestion and atelectasis in the left lower lobe, and SOB on exertion.

Goal: Pt. will have adequate oxygenation and absence of shortness of breath within 2 days.

Interventions:
1. Auscultate breath sounds every 4 hours and note adventitious sounds, note respiratory rate, depth, and use of accessary muscled. Encourage the use of the incentive spirometer and deep breathing exercises every hour, stressing the important role it plays in her progress.

2. Review and compare chest x-rays once a day, review notes written in final report.

3. Monitor Intake and Output every 2-4 hours

4. Elevate the head of the bead every day to maintain open airway.

5. Encourage deep breathing,...

References: (1) Doenges, Marilynn E., Mary Frances Moorhouse, and Alice C. Murr. Nurse 's Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales. Philadelphia: F.A. Davis, 2010. Print.
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