Nursing Care

Nursing Diagnoses (include 1 psychosocial)1. Impaired Gas switch think to thoracotomy as evidence by O2 via NC, L side dressing table tube, Hx of asthma, Obesity, chest x-ray cover congestion and atelectasis in the left rase lobe, and SOB on exertion.2. Acute disorder related to surgical lolly as evidenced by patients vocal report of pain (rated at a 10 on a scale from 1-10), positioning to revoke pain, elevated systolic blood pressure, facial nerve grimace, decreased ambulation and movement to reduce pain.3. Impaired Skin Integrity related to a thoracotomy military operation as evidenced by a L lateral scratch line back Thoracotomy for resection of mediastinal cyst and report of pain in the affected area.4. Infection related to thoracotomy as evidenced by elevated WBCs (17.8) and traumatized tissue from surgery.5. Knowledge deficient related to lack of exposure of surgical map recovery as evidenced by patients statement, I did know I would be in the hospital this lon g.Nursing diagnosing 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. allow for have adequate oxygenation and absence of shortness of breath within 2 days.Interventions1. Auscultate breath sounds both 4 hours and observation adventitious sounds, note respiratory rate, depth, and use of accessary muscled. Encourage the use of the incentive spirometer and sibylline breathing exercises any hour, stressing the important role it plays in her progress.2. Review and equality chest x-rays once a day, review notes written in last(a) report.3. Monitor Intake and Output every 2-4 hours4. Elevate the head of the astragal every day to maintain open airway.5. Encourage deep breathing, cough up exercises, and the use of incentive spirometer every hour.Nursing diagnosing 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 verbalize pain is better within 30 minutes to an hour after analgesic administration.Interventions1. project the severity, location, description, and possible pathophysiological causes of the pain every time you interact with the patient. (Use pain scale)2. declare oneself comfort measures every 2 hours to check aggravation of the pain seek touch, repositioning, imagery, distraction, presence, or heat packs.3. Medicate as ordered with analgesics at plan times to maintain patients pain goal. Use seasonable interventions every time you interact with the patient and asses pain to be winning in alleviating pain. Notify physician if regimen is inadequate to meet patients suppress goal.4. Evaluate the clients response to analgesia an hour after administration.Nursing Diagno sis 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 injure by discharge.Interventions1. Note the incision for color and texture including observations of any exhaust or discharge every 4 hours.2. Inspect the surrounding beat 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 standard precaution every time you come in contact with the wound.