Nursing Diagnosis #1 Impaired Gas Exchange related to decreased oxygen supply secondary to...
-
Upload
charles-davis -
Category
Documents
-
view
229 -
download
0
Transcript of Nursing Diagnosis #1 Impaired Gas Exchange related to decreased oxygen supply secondary to...
Nursing Diagnosis #1Nursing Diagnosis #1
Impaired Gas Exchange related to decreased oxygen supply secondary to bronchiectasis and atelectasis as evidenced by:◦ increased CO2 levels to 33◦decreased respiratory rate to 4 bpm◦need for mechanical ventilation◦pale skin ◦dyspnea ◦restlessness
Nursing Diagnosis #1Nursing Diagnosis #1
Patient Goals:◦B.L.B will maintain a respiratory rate between
12-20 breaths per minute.◦B.L.B. will expectorate sputum and cough
effectively.◦B.L.B. will have normal breath sounds.
Nursing Diagnosis #1Nursing Diagnosis #1
Patient Interventions:◦Place B.L.B with the head of the bed elevated
to help facilitate chest expansion.◦Monitor B.L.B’s vital signs every hour to detect
tachypnea and tachycardia.◦Perform tracheostomy suctioning as needed to
help remove secretions.◦Change patient’s position every two hours to
mobilize secretions and allow aeration of lung fields.
◦Give bronchodilator medications at scheduled times to dilate bronchioles and provide gas exchange.
Nursing Diagnosis #1Nursing Diagnosis #1
Evaluation of Interventions: Goal Partially Met◦Patient’s respiratory rate remained between
12-20 bpm for most of the day◦Patient maintained adequate oxygenation when
switched from spontaneous intermittent mechanical ventilation to continuous positive airway pressure.
◦Patient did not experience dyspnea when resting.
Nursing Diagnosis #2Nursing Diagnosis #2
Impaired Physical Mobility related to pain and discomfort secondary to hemiarthroplasty and right elbow hardware removal and soft tissue repair as evidenced by:◦Limited ROM in left leg and right arm◦Difficulty turning◦Slowed movement of upper extremities◦Shortness of breath with turning and supine
postition
Nursing Diagnosis #2Nursing Diagnosis #2
Patient Goals◦B.L.B. will report a pain level between 0-3 on
numerical scale of 0-10.◦B.L.B. will perform range of motion with left
arm and right leg as much as possible.◦B.L.B. will have no shortness of breath with
turning.
Nursing Diagnosis #2Nursing Diagnosis #2
Patient Interventions:◦Monitor and document B.L.B.’s functional ability
throughout day to notice improvement and decline in ability.
◦Encourage patient to report pain or discomfort and observe for nonverbal cues of pain to aide in physical mobility.
◦Implement ROM exercises every shift to prevent contracture and muscle atrophy
◦Reposition B.L.B. every two hours to prevent skin breakdown
Nursing Diagnosis #2Nursing Diagnosis #2
Evaluation of Interventions: Goal Partially Met◦Patient ‘s pain level remained below 3 for most
of the day◦Patient had increased mobility of left arm but
now right leg◦Patient did not display any evidence of
contractures or skin breakdown
Nursing Diagnosis #3Nursing Diagnosis #3
Risk for Infection related to surgical incision secondary to hemiarthroplasty right elbow hardware removal and soft tissue repair, and neck mass biopsy as evidenced by:◦Incision on left hip◦Incision under cast on right arm ◦Incision on right side of neck
Nursing Diagnosis #3Nursing Diagnosis #3
Patient Goals:◦B.L.B’s vital signs will remain within normal limits
◦B.L.B.’s incisions will remain free from signs and symptoms of infection
◦B.L.B.’s will not have any dishescence
Nursing Diagnosis #3Nursing Diagnosis #3
Patient Interventions◦Wash hands before and after handling area
around wounds.◦Monitor dressing for intactness and drainage◦Use sterile techniques as needed for dressing
changes◦Monitor incisions for signs of infection, such as
redness, tenderness, and swelling.◦Monitor vital signs, especially temperature,
every hour.
Nursing Diagnosis #3Nursing Diagnosis #3
Evaluation of Interventions: Goal Met◦B.L.B.’s axillary temperature remained below
100˚F throughout day◦B.L.B’s incision site remained free from
erythema, edema, tenderness, warmth, and purulent drainage.
◦B.L.B’s wound edges remained approximated with no evidence of dishescence.