Question

• Do a head to toe assessment and put it in narrative form
• Document the history, labs, and diagnostic procedures
• What would be the nurse management?
• Write out a careplan:
  • Subjective
  • Objective
  • Nursing Diagnosis
  • Goal
  • Implementation
  • Evaluation
• The scenario is:
  • A 40 yo male is seen in the ED with SOB, diaphoretic, thrush, pain in the LLL.
  • A chest xray was ordered and it showed a tumor in the RML, and a pneumothorax in the LLL.
  • The PaO2 46, and the PaCO2 was 51
  • The doctor placed a chest tube and connected the tube to the pleuravac to low continuous suction.

Answer 1

Subjective

• Breathlessness
• Thrush
• Pain

Objective

• Diaphoretic
• PaO2 46 (low)
• PaCo2 51(high)
• Tumor in RML
• Pneumothorax

Nursing diagnosis

Impaired gaseous exchange related to leakage of air, tumor in the lung as evidenced by shortness of breath increased Co2 level and decreased oPaO2 level .

Goal

The patient will have normal breathing pattern

Implementation

• Administer oxygen as per order
• Monitor the chest tube for any leakage ,kinks to prevent any unnecessary unexpected complications
• Provide patient propped up position to improve the lung capacity and improve airwau
• Place the chest tube drainage system should be below the chest level
• Assess the patient throughout the shift

Evaluation

The patient is having a normal gaseous exchange