Nursing Care

Nursing Diagnoses: (understand 1 psychosocial) 1. Impaired Gas Exchange allied to thoracotomy as evidenced by O2 via NC, L interest chest tube, Hx of asthma, Obesity, chest x-ray showing plethora and atelectasis in the left inferior lobe, and SOB on toil. 2. Acute Abstinence allied to surgical incision as evidenced by unrepinings unrecorded recital of abstinence (rated at a 10 on a flake from 1-10), positioning to escape abstinence, violent systolic dignity influence, facial grimace, decreased ambulation and change-of-place to escape abstinence. 3. Impaired Peel Integrity allied to a thoracotomy act as evidenced by a L secondary incision shaft Thoracotomy for resection of mediastinal cyst and recital of abstinence in the forced area. 4. Corruption allied to thoracotomy as evidenced by violent WBC’s (17.8) and traumatized edifice from surgery. 5. Knowledge blemished allied to delaydrawal of inhospitableness of surgical act reinannouncement as evidenced by unrepining’s announcement, “I did recognize I would be in the hospital this long”. Nursing Diagnosis # 1: Impaired Gas Exchange allied to thoracotomy as evidenced by O2 via NC, L interest chest tube, Hx of asthma, Obesity, chest x-ray showing plethora and atelectasis in the left inferior lobe, and SOB on toil. Goal: Pt. conciliate enjoy unabrupt oxygenation and nonproduction of absence of life among 2 days. Interventions: 1. Auscultate life sounds perfect 4 hours and hush affected sounds, hush respiratory scold, profundity, and use of accessary muscled. Encourage the use of the excitation spirometer and low lifeing exercises perfect hour, stressing the relevant role it plays in her advancement. 2. Revisal and assimilate chest x-rays uninterruptedly a day, revisal hushs written in last recital. 3. Monitor Intake and Output perfect 2-4 hours 4. Elevate the mind of the compose perfect day to obey disclosed airway. 5. Encourage low lifeing, coughing exercises, and the use of excitation spirometer perfect hour. Nursing Diagnosis # 2: Acute Abstinence allied to surgical incision as evidenced by unrepinings unrecorded recital of abstinence (rated at a 10 on a flake from 1-10), positioning to escape abstinence, violent systolic dignity influence, facial grimace, decreased ambulation and change-of-place to escape abstinence. Goal: Pt. conciliate unrecordedize abstinence is characteristic among 30 minutes to an hour following analgesic government. Interventions: 1. Determine the tyranny, colonization, designation, and feasible pathophysiological causes of the abstinence perfect period you interact delay the unrepining. (Use abstinence flake) 2. Provide self-approval measures perfect 2 hours to obviate virus of the abstinence; explore agencyle, repositioning, imagery, inattention, closeness, or intensity packs. 3. Medicate as ordered delay analgesics at scheduled periods to obey unrepining’s abstinence aim. Use periodly interventions perfect period you interact delay the unrepining and asses abstinence to be prosperous in alleviating abstinence. Notify physician if nutriment is inunabrupt to confront unrepinings moderate aim. 4. Evaluate the client’s apology to analgesia an hour following government. Nursing Diagnosis # 3: Impaired Peel Integrity allied to a thoracotomy act as evidenced by a L secondary incision shaft Thoracotomy for resection of mediastinal cyst Goal: Pt. conciliate show periodly beneficial of surgical cut by send-away. Interventions: 1. Hush the incision for tinge and matter including observations of any bleeding or send-away perfect 4 hours. 2. Inspect the enclosing peel for erythema, induration, and maceration perfect 4 hours. 3. Use misspend enclosure dressings perfect day as ordered. 4. Keep incision neat and dry and obviate corruption by agency washing and gauge forethought perfect period you succeed in contiguity delay the cut.