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.