Nursing Diagnosis : 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
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.
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.
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 : 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
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.
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
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 : 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
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
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.
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.