How post-op is this patient? Just recently, like in the past few days? If so, this is a surgical patient with a large thoracotomy incision and a chest tube. May still be on a ventilator, or not. Definitely will need to address breathing, oxygen and airway issues. Prevention of pneumonia in the non-operative side is important. Care of the chest tube. Coughing and deep breathing--crucial. The patient will be in a lot of pain and won't want to move. With TPN infusing as well as being post-op thoracotomy this patient will have central IV access and attention needs to be paid to the dressings on this access device. If immediate post-op there may some hemodynamic monitoring going on yet. Some potential nursing diagnoses:
- Impaired Gas Exchange
- Ineffective Airway Clearance
- Ineffective Breathing Pattern
- Activity Intolerance
- Imbalanced Nutrition: less than body requirements
- Impaired Skin Integrity
- Acute Pain
- Risk for Infection
- Risk for Fluid Volume Excess
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