Nursing Care

Nursing Diagnoses: (include 1 psychosocial)
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.
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.

3. Impaired Skin Integrity related to a thoracotomy procedure as evidenced by a L lateral incision post Thoracotomy for resection of mediastinal cyst and report of pain in the affected area.
4. Infection related to thoracotomy as evidenced by elevated WBC’s (17.8) and traumatized tissue from surgery.
5. Knowledge deficient related to lack of exposure of surgical procedure recovery as evidenced by patient’s statement, “I did know I would be in the hospital this long”.
Nursing Diagnosis # 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. will have adequate oxygenation and absence of shortness of breath within 2 days.
Interventions:
1. Auscultate breath sounds every 4 hours and note adventitious sounds, note respiratory rate, depth, and use of accessary muscled. Encourage the use of the incentive spirometer and deep breathing exercises every hour, stressing the important role it plays in her progress.
2. Review and compare chest x-rays once a day, review notes written in final report.
3. Monitor Intake and Output every 2-4 hours
4. Elevate the head of the bead every day to maintain open airway.
5. Encourage deep breathing, coughing exercises, and the use of incentive spirometer every hour.
Nursing Diagnosis # 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 relieved within 30 minutes to an hour after analgesic administration.
Interventions:
1. Determine the severity, location, description, and possible pathophysiological causes of the pain every time you interact with the patient. (Use pain scale)
2. Provide comfort measures every 2 hours to prevent aggravation of the pain;
explore touch, repositioning, imagery, distraction, presence, or heat packs.
3. Medicate as ordered with analgesics at scheduled times to maintain patient’s pain goal. Use timely interventions every time you interact with the patient and asses pain to be successful in alleviating pain. Notify physician if regimen is inadequate to meet patients control goal.
4. Evaluate the client’s response to analgesia an hour after administration.
Nursing Diagnosis # 3:
Impaired Skin Integrity related to a thoracotomy procedure as evidenced by a L lateral incision post Thoracotomy for resection of mediastinal cyst
Goal: Pt. will display timely healing of surgical wound by discharge.
Interventions:
1. Note the incision for color and texture including observations of any bleeding or discharge every 4 hours.
2. Inspect the surrounding skin 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.