Nursing Care

Nursing Diagnoses (include 1 psychosocial)1. impaired waste Exchange relate to thoracotomy as bear witness by O2 via NC, L attitude white meat tube, Hx of asthma, Obesity, chest x-ray demo over-crowding and atelectasis in the left put down lobe, and dent on exertion.2. Acute painful sensation related to operative moolah as certify by forbearings verbal cover of pain (rated at a 10 on a scale from 1-10), lay to subjugate pain, promote systolic daub pressure, facial grimace, rock-bottom ambulation and movement to avoid pain.3. stricken Skin Integrity related to a thoracotomy procedure as evidenced by a L squint-eyed chicken feed post Thoracotomy for resection of mediastinal cyst and get over of pain in the affected area.4. transmitting related to thoracotomy as evidenced by elevated WBCs (17.8) and traumatized thread from surgery.5. Knowledge deficient related to pretermit of exposure of surgical procedure convalescence as evidenced by patients statement, I d id know I would be in the hospital this spacious.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 able oxygenation and absence of shortness of breath deep down 2 days.Interventions1. Auscultate breath sounds both 4 moments and take down adventitious sounds, note respiratory rate, depth, and aim of accessary muscled. ejaculate on the use of the incentive spirometer and deep active exercises all(prenominal) hour, stressing the important role it plays in her progress.2. Review and compare chest x-rays formerly a day, review notes written in final report.3. Monitor Intake and rig any 2-4 hours4. Elevate the head of the form every day to wield absolved airway.5. Encourage deep breathing, coughing exercises, and the use of incentive spirometer every hour.Nursing Diagnosis 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.Goal Pt. will blab pain is relieved within 30 minutes to an hour after moderating administration.Interventions1. Determine the severity, location, description, and possible pathophysiological causes of the pain every time you interact with the patient. ( procedure pain scale)2. post comfort measures every 2 hours to disallow aggravation of the pain explore touch, repositioning, imagery, distraction, presence, or heat packs.3. Medicate as reproducible with analgesics at scheduled times to maintain patients pain goal. Use by the way interventions every time you interact with the patient and asses pain to be prospered in alleviating pain. Notify physician if victuals is inadequate to meet patients control goal.4. approximate the clients response to analgesia an hour after administration.Nursing Diagnosis 3 Impaired Skin Integrity related to a thoracotomy procedure as evidenced by a L lateral incision post Thoracotomy for resection of mediastinal cystGoal Pt. will display timely healing of surgical wound by fell.Interventions1. Note the incision for color and food grain including observations of any bleeding or discharge every 4 hours.2. Inspect the surround skin for erythema, induration, and maceration every 4 hours.3. Use appropriate barrier dressings every day as ordered.4. Keep incision clean and dry and prevent infection by hand washing and beat precaution every time you come in contact with the wound.