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N Nursing Expected Nursing Intervention Rationale Evaluation

o Problem Outcomes
1. Impaired gas The pt. will i. Note respiratory Respiratory may be increase as The pt. can
exchange be able to rate, depth and ease a result of pain. Increase work of demonstrate improve
related to demonstrate of respirations. breathing and cyanosis may ventilation and
increase improve Observe for the use indicate increasing oxygen adequate oxygenation
production of ventilation of accessory muscle, consumption and energy of tissue by ABGs
bronchial and pursed lip breathing, expenditures and reduced within pt. normal
secretions. adequate changes in skin @ respiratory reserve. range.
oxygenation mucus membrane
of tissue by colour.
ABGs within ii. Auscultate lungs air
pt. normal movement and Consolidation and lack of air
range. abnormal breath movement on operative side are
sound. normal in the pneumonectomy.

iii. Investigate May indicate increase hypoxia @

restlessness and complications.
changes in
mentation level @
level of
consciousness. Airway obstruction impedes
ventilation, impairing gas
iv. Maintain patent exchange.
airway by
suctioning, use of Maximize lung expansion and
airway adjuncts. drainage of secretions.

v. Reposition
frequently, placing
pt. in sitting position Promotes maximal ventilation
and semi-fowler’s and oxygenation and reduces
position. @prevent atelectasis.

vi. Encourage @ assist

with deep breathing
exercises as
2. Deficient The pt. will i. Elicit pt. Many pt. exposed to someone
knowledge due be able to understanding of with lung cancer get many
to unfamiliarity describe the causes, diagnostic misconceptions continue to
with causes, causes, evaluation and exist.
diagnostic diagnostic treatment for lung
evaluation and evaluation cancer.
treatment. and
treatment. ii. Identify and Many sources have numerous
communicate to teaching aids available to
the pt. community support and reinforce learning.
resources, Increasing motivation to learn.
websites and Warn the pt. about resources
additional sources that do not provide correct
of information and information.

iii. Explain possible The pt. may benefit from

causes of lung understanding the broad range
cancer: of causes for lung cancer.
- tobacco use
- passive expose
to smoke
- radon, asbestos
- air pollution
- exposure to
agent (petroleum)
Continued smoking in the face of
iv. If pt. is a smoker: a diagnosis of treatable lung
Discuss strategies cancer may hasten the pt.
for stop smoking: death.
- use of nicotine
- use of nicotine
- behavior
- stop smoking
support group. Often during the acute stages,
the family may require the most
v. Assess the family teaching. This can assist them in
member to providing support to the pt.
participate in the
teaching and
learning process.
3. Acute pain Pt. i. Assess for pain Each individual may exhibit
verbalizes severity and slightly different pain
relief of @ defining presentation. Bone pain is
ability to characteristics. common.
pain. Pt. also ii. Assess the pt. Some pt. may be content to
appears expectations for have pain decrease.
relaxed and pain relief.
iii. Monitor effectiveness Pt. have a right to effective pain
of pain therapies. relief use of visual analog scales
may provide objective data.
iv. Assess side effect of Long term use may result in side
pain therapies, effects.

v. Teach Massage, distraction, music

nonpharmacologic therapy and support groups may
al interventions enhance pharmacological
for pain relief. interventions.

vi. Administer prescribe

medications. Various medication may be
given by a verity of routes
including pt.-controlled analgesia
(PCA) in which the pt. can
control the amount of
medication delivered.