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need for nursing care plan for Hemothorax

by Raghad1419 Raghad1419 (New) New Student

Admitted 22 years old male patient due to Traffic Road Accident, unconscious, patient attached to cardiac monitor, his initial vital signs are: heart rate 147 beats per minute, blood pressure 82/41 mmHg, respiratory rate 24 and oxygen saturation of 90%, the patient was found on chest radiography to have several broken ribs and hemothorax. The physician placed a large bore chest tube in order to drain the blood and 900cc of blood was evacuated in pleural vac, CT scan revealed that the patient has spleen injury, patient was taken to operating room for thoracotomy, in the operating room patient received 5 units Packed Red blood cells and 3 units frozen plasma.

After operation he was admitted at ICU on ventilator machine with Vital signs of BP 110/70, RR 24,HR 110,and temperature 38 degrees, chest tube output, 60cc/hour.

Medication given was aeknil 300 mg iv every 4 hours, cefuroxime 500 mg iv every 8 hours.

Latest Laboratory results

WBC 14.5 K/uL

RBC 3.68 M/uL

Hemoglobin 9 g/dL

Hct 35 %

Platelet 153 K/uL

what the NCP for this patient ?

I need nursing diagnosis, please, I'm searching for something but I'm not sure if it's right or wrong 😭

Edited by Raghad1419

Rose_Queen, BSN, MSN, RN

Specializes in OR, education. Has 16 years experience.

Hello, @Raghad1419. Why don't you go ahead and share with us what you think are priority nursing diagnoses and you'll receive feedback on what you share.

@Rose_Queen this it the diagnosis

Acut Pain r/t chest surgery e/b Autonomic response

Ineffective breathing pattern r/t decreased lung expansion evidence by tachypnea

Hyperthermia R/T increase in metabolic rate : sepsis as evidence by body temperature 38 + tachypnea

Impaired tissue integrity r/t trauma Evidence by damaged tissue

Risk for decreased cardiac output related to mechanical ventilator

Do you need to list them in order of priority?

For pain, you need to give actual s/s. At least when I did care plans, “autonomic response” wouldn’t be accepted. I would have to list what actual s/s my patient was exhibiting.

I would say ineffective breathing pattern is a good one. The broken ribs and hemothorax shown by the diagnostic tests can also be listed as evidence.

I’d say given his labs, there’s another priority diagnosis you should have listed.

Given the temp is 100.4 F, I would say there’s more priority diagnoses than hyperthermia. If the temp was higher than I’d consider that. But, others might disagree there, so maybe see what others say about it and go from there.

Was this info you were given, like a case study or did you assess the patient yourself?

Edited by KrCmommy522