Nursing Diagnosis #1

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 #1

2. 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

3. 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

4. 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 #1

5. 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

6. 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

7. 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

8. 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 #2

9. 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

10. 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

11. 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

12. 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