Question

Read the following scenario. Complete a care plan with at least 2 NANDA approved nursing diagnoses, at least 3 interventions for each diagnosis, and the rationale behind all. Please refer to the article posted in the Updates to review the NANDA approved diagnoses and how and why they are utilized.

Mr. Emery was admitted to the hospital to have a lung biopsy and resection. Following surgery, he is transferred to the surgical unit with two right pleural chest tubes connected to pleur-evac systems with 20 cm of dry suction. Chest tube A is anterior and chest tube B is lower and posterior.

Orders Include:

Up to the chair as tolerated

Cough and deep breath 10 times per hour

Change dressing daily

IV of Lactated ringers at 75 ml/hour

Regular diet

Answer 1

Lung biopsy

The removal and examination of a sample of lung tissue from a living body for diagnostic purposes is called lung biopsy.

Resection

The surgical excision of part or all of a tissue or organ is called resection.

Post operative Nursing diagnosis for Mr. Emery:

1. Impaired gas exchange related to removal of lung tissue as evidenced by ( hypoxemia/ hypercapnea/ dyspnea)

Goal/ Desired outcome : Demonstrate adequate oxygenation of tissues by Arterial Blood Gas analysis within normal range.

Interventions

* Monitor rate , ease, depth of respiration : To get baseline information; respiration may increase in order to compensate the loss of lung tissue/ respiratory rate may increase due to pain also ( rationale)

* Check for any changes in the skin and mucous membrane colour such as cyanosis, pallor : Cyanosis is an indication of hypoxemia .

* Maintain patent airway by positioning ( sitting position and supine to side position), suctioning : for lung expansion ( positioning) and drainage of secretion.

* Check and maintain the patency of tubes for chest drainage system for patient ( undergone resection or lobectomy):   

fluid drainage from the pleural cavity helps in the expansion of remaining lung segments.

* Administer supplemental oxygen as prescribed : to reduce hypoxemia

2. Acute pain related to surgical incisions/ presence of chest tubes as evidenced by ( verbal reports of discomfort , by facial expression)

Goal or desired outcome:

Patient will report pain relieved / patient will appear relaxed

Interventions

1. Assess the level of pain by pain scale/ ask the patient about the type of pain ( stabbing pain or continuous aching): to get the base line data / pain scale may help in evaluating the effect of analgesics.

2. Provide comfortable position( sitting or side , notupport with pillows, back rubs :    Relieves discomfort

3. Assist with self care activities and breathing exercises:

to prevent incisional strain and undue fatigue

4. Provide relaxation techniques ( guided imagery ) or diversional therapy , example: watching TV : redirects attention and promote relaxation.

5. Provide patient controlled analgesia as per prescription :

To relive pain or to reduce pain and to improve respiratory function and to improve emotional state of the patient.

3. Anxiety related to hospitalization or change in health status ad evidenced by ( withdrawal, anger)

Intervention

1. Assess the patient's level of understanding about the diagnosis and surgery : Helps the nurse to choose appropriate intervention

2. Provide clarification for patient's doubts and answer the honestly : Helps in reduce misperception and helps in establishing the trust .

3. Involve patient and family members in planning the interventions : Increase the patient's confidence or his feeling on control over his health.