Cues

Nursing Diagnosis

Inference

Objective

Nursing Intervention

Rationale

Evaluation

Subjective
◊ “Nahihirapan siya na huminga pagkatapos nung aksidente na nangyari” as verbalized by sister.

◊ Ineffective airway clearance r/t lung impairment

Objective
◊ use of accessory muscles during inhalation & expiration ◊ restlessness ◊ c chest tube intact & draining to dark red exudates ◊ draining output is moderate in amount ◊ V/S as follows: T= °C P= bpm R= cpm BP= / mmHg

◊ Due to the trauma that has occurred over the ribs, an intense inflammatory response occurred. Exudation of plasma, leukocytes, infiltration of mast cells, growth factors and inflammatory leukocytes occurs in effect. These fluid and exudates crosses the permeable membrane of the pleurae causing it to accumulate in this membranous space. Instead of the lungs being able to function normally, these fluids inhibit the lungs to expand anteroposteriorly thus causing ineffective breathing & discomfort.

Short Term Goal
◊ After 10 minutes of nursing intervention, patent airway is achieved & there is improvement in the airway clearance.

Independent
◊ Maintained an open airway. ◊ Performed endotracheal suctioning until she can raise secretions effectively. ◊ Provides for adequate ventilation and gas exchange ◊ Endotracheal secretions are present in excessive amounts in post-thoracotomy patients due to trauma to the tracheobronchial tree during surgery, diminished lung ventilation and cough reflex. ◊ Helps to achieve maximal lung inflation and to open closed airways. ◊ Changes in sputum suggests presence of infection or change in pulmonary status. Opacisication or coloration of sputum may indicate dehydration or infection otherwise. ◊ Chest physiotherapy uses gravity to help remove secretions from the lungs. ◊ Indications for tracheal suctioning are determined by chest auscultation. ◊ Secretions must be moistened and thinned if they are to be raised from the chest with the least amount of effort.

◊ After 10 minutes of nursing intervention, goal is met through the patency of airway, demonstration of effective exercises when coughing & lungs are clear on auscultation.

◊ Pain was assessed. Encouraged deep breathing and coughing exercise. ◊ Amount, viscosity, color and odor of sputum were monitored.

◊ Performed postural drainage, percussion and vibration as prescribed. ◊ Determined changes in breath sounds through auscultation.

Dependent
◊ Administered humidification & nebulizer therapy as prescribed.

Cues

Nursing Diagnosis

Inference

Objective

Nursing Intervention

Rationale

Evaluation

Subjective
◊ “Kumikirot pa ang naoperahan sa kanya kaya siya di makausap at makatulog mabuti,” as verbalized by sister.

◊ Acute Pain r/t incision, drainage tubes & surgical procedure

Objective
◊ positive facial grimace ◊ weakness ◊ pain intensity is 7/10 ◊ irritable ◊ V/S as follows: T= °C P= bpm R= cpm BP= / mmHg

◊ Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from seconds to 6 months. In cases of fracture, pain is continuous & increasing in severity but will subside significantly on the 5th to 7th day. Pain may be attributed to the increase of pressure caused by the increase production of exudates thus causing pain radiating over the site.

Short Term Goal
◊ After 30 minutes of nursing intervention, pain intensity as verbalized will be lessened from 7/10 to 4/10.

Independent
◊ Location, character, quality and severity of pain was evaluated. ◊ Maintained care in positioning the patient. Placed in a semiFowler’s position & turned every 2 hours. ◊ Pain limits chest excursion and thereby decreases ventilation. ◊ The patient who is comfortable and free of pain will be less likely to splint the chest while breathing. A semi-Fowler’s position permits residual air in the pleural space to rise to upper portion of pleural space and be removed. ◊ These signs indicate possible infection.

◊ After 30 minutes of nursing intervention, the goal is met through the patient verbalizing that she is free of acute distress and feels much more comfortable. There is no sign of incisional infection.

◊ Incision area was assessed every 8 hours for redness, heat, induration, swelling and drainage.

Dependent
◊ Administered analgesics as prescribed. ◊ Analgesics give pain relief on the part of the patient.

Cues

Nursing Diagnosis

Inference

Objective

Nursing Intervention

Rationale

Evaluation

Subjective
◊ “Hindi siya gaano makakilos gawa nung mga nakalagay sa kanya,” as verbalized by sister.

◊ Impaired physical mobility of the upper extremities r/t thoracotomy

Objective
◊ c chest tube drainage on L lateral abdomen ◊ restlessness

◊ Impaired ability to perform dressing & toileting as part of activities of daily living is due to contraptions within the abdominal area. Movement is limited and often is obstructed by the tubings.

Short Term Goal
◊ After 3 days of nursing intervention, she demonstrates and verbalizes proper exercises of the upper extremities & can perform activities of daily living gradually..

Independent
◊ Patient was assisted with normal range of motion and function of shoulder and trunk. Proper breathing exercises to mobilize thorax were advised. ◊ Encouraged progressive activities according to level of fatigue. ◊ Necessary to regain normal mobility of arm and shoulder to speed recovery.

◊ Increase patient’s use of affected shoulder and arm.

◊ After 3 days of nursing intervention, goal is met through the regaining of the patient’s previous range of motion in the shoulders and arms & demonstrates proper exercises for the upper extremities. She also does ADL without discomfort.

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