Impaired Gas Exchange related to decreased oxygen supply

�Impaired Gas Exchange related to decreased oxygen supply secondary to bronchiectasis and atelectasis as evidenced by: ◦ increased CO 2 levels to 33 ◦ decreased respiratory rate to 4 bpm ◦ need for mechanical ventilation ◦ pale skin ◦ dyspnea ◦ restlessness Nursing 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 #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 #1

�Evaluation Met of Interventions: Goal Partially ◦ Patient’s respiratory rate remained between 1220 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 #1

�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 #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 #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 #2

�Evaluation Met of Interventions: Goal Partially ◦ 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 #2

�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 #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 #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 #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. Nursing Diagnosis #3