Nursing Diagnosis #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 Patient Goals: ◦B.L.B will maintain a respiratory rate between breaths per minute. ◦B.L.B. will expectorate sputum and cough effectively. ◦B.L.B. will have normal breath sounds.

Nursing Diagnosis #1 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 Evaluation of Interventions: Goal Partially Met ◦Patient’s respiratory rate remained between 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 #2 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 Patient Goals ◦B.L.B. will report a pain level between 0-3 on numerical scale of ◦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 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 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 #3 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 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 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 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.