NURSING CARE PLAN 28-2

Patient After Thoracotomy

NURSING DIAGNOSIS Ineffective Breathing Pattern
related to pleural fluid collection, chest tube
placement, pain, and body position as
evidence by shallow respirations, altered chest
ecursion, and dyspnea
!A"I#N" GOA$ Demonstrates an effective rate, rhythm, and
depth of respirations
OU"%O&#S 'NO%( IN"#R)#N"IONS 'NI%( AND RA"IONA$#S
Respiratory Status
Respiratory rate ***********
Respiratory rhythm *********
Depth of inspiration *********
Achievement of epected incentive
spirometer ********
Auscultated breath sounds *******
Oy+en saturation ********
&easurement scale
, - Severe deviation from normal ran+e
. - Substantial deviation from normal ran+e
/ - &oderate deviation from normal ran+e
0 - &ild deviation from normal ran+e
1 - No deviation from normal ran+e
enti!ation A""i"tance
Assist with fre2uent position chan+es
to promote draina+e of poc3ets of fluid4
#ncoura+e slow deep breathin+,
turnin+, and cou+hin+ to control
respiratory pattern4
Assist with incentive spirometer to
provide visual feedbac3 to the patient
on effectiveness of respirations4
Auscultate breath sounds, notin+ areas
of decreased5absent ventilation and
presence of adventitious sounds4
Administer appropriate pain medication
to prevent hypoventilation4
!osition to minimi6e respiratory efforts
'e4+4, elevate the head of the bed and
provide overbed table for patient to
lean on(4
Ambulate / to 0 times a day to promote
deep breathin+ and lun+ reepansion4
NURSING DIAGNOSIS Ri"# for infection
related to tissue in7ury, placement of chest
tubes
!A"I#N" GOA$S ,4 #periences no indication of infection
.4 Incision and stab wounds heal by first
intention
OU"%O&#S 'NO%( IN"#R)#N"IONS 'NI%( AND RA"IONA$#S
Infection Severity
!urulent draina+e *******
!urulent sputum ********
%hest 8ray infiltration *****
9ever *****
!ain5tenderness******
:hite blood cell count elevation *****
Sputum culture coloni6ation ******
Infection Protection
&onitor for systemic and locali6ed
si+ns and symptoms of infection to
enable early detection and treatment4
Inspect condition of sur+ical
incisions5wounds to detect early si+ns
of infection4
#ncoura+e increased mobility and
eercise to increase circulation and
:ound site culture coloni6ation *****
&easurement Scale
, - Severe
. - Substancial
/ - &oderate
0 - &ild
1 - None
promote healin+4
Obtain cultures as needed to identify
causative a+ents and effective
antibiotics4
T$%e Care& Che"t
&onitor for bubblin+ of the suction
chamber of the chest tube draina+e
system and tidalin+ in water8seal
chamber to ensure ade2uate
ventilation4
#nsure that all tubin+ connections are
securely attached and taped to prevent
air lea3s4
;eep the draina+e container below
chest level to prevent pneumothora4
Observe volume, shade, color, and
consistency of draina+e from lun+, and
record appropriately, to detect
infection4
%lean around the tube insertion site to
decrease eposure to patho+ens4
%han+e dressin+ around chest tube
every .<8=. hr as needed to monitor
side and provide protection4
NURSING %AR# !$AN /,8/
!atient with Neutropenia
NURSING DIAGNOSIS Ri"# for infection
related to inade2uate secondary defenses
'leu3openia, neutropenia(, altered response to
microbial invasion, and environmental
eposure to patho+ens
!A"I#N" GOA$S ,4 Adheres to infection control and
protection practices
.4 #periences no si+ns or symptoms of
infection, reducin+ the ris3 of septic
shoc3
OU"%O&#S 'NO%( IN"#R)#N"IONS 'NI%( AND RA"IONA$#S
Ris3 %ontrol
Ac3nowled+es ris3 factors ****
9ollows selected ris3 control strate+ies
****
Avoids eposure to health threats ****
&odifies lifestyle to reduce ris3 ****
Infection Severity
!urulent sputum ****
!urulent draina+e ****
Infection Contro!
&aintain isolation techni2ues as
appropriate to reduce eposure to
environmental patho+ens4
:ash hands before and after each
patient care activity to prevent
transmission of patho+ens4
Use antimicrobial soap for hand
washin+4
Instruct visitors to wash hands on
%hest 8ray infiltration ****
9ever ****
!ain5tenderness ****
>lood culture coloni6ation ****
:hite blood count elevation ****
&easurement Scale
, - Severe
. - Substantial
/ - &oderate
0 - &ild
1 - None
enterin+ and leavin+ patient?s room to
prevent the transmission of harmful
patho+ens to patient4
"each patient and care+iver how to
avoid infections 'e4+4, personal hy+iene
techni2ues of hand washin+, oral care,
s3in hy+iene, and pulmonary hy+iene(4
"each the patient and care+ivers about
si+ns and symptoms of infection and
when to report them to the health care
provider to receive early treatment of
infection4
Instruct patient to ta3e antibiotics as
prescribed to prevent microbial
resistance4
Infection Protection
&onitor for systemic and locali6ed
si+ns and symptoms of infection to
promote early detection of infection4
&onitor absolute +ranulocyte count,
:>% count, and :>% differential
results to identify si+ns of and potential
for infection4
Inspect s3in and mucous membranes
for redness, etreme warmth, or
draina+e4
9ollow neutropenic precautions to
avoid eposure to patho+ens4
"each patient the importance of and
proper procedure for hand washin+4
Report suspected infections to infection
control personnel in order to promptly
initiate antibiotic therapy4
Remove fresh flowers and plants from
patient areas to avoid introduction of
patho+ens4