Nees help with Pneumothorax dx plz!

[Passion4Caring]

hey everyone, i am looking for some help on my care plan please. i need more diagnoses for a pt 71 yrs old, dx with r. pneumothorax secondary to port a cath insertion. i had this pt the following day her chest tube was inserted.

a little info on the pt:

this is the pt's 2nd admission to the hospital secondary to recent plastic surgery in costa rica. she had a surgical resection of the external fat of her arms. after returning to the us, pt reported that she was not feeling well, so she went to the hosital where she was dx with an infection (possibly staph/mrsa). pt stayed in the hospital for 2 weeks, and before being sent home a port a cath was inserted so that she could continue to be treated for the infection. pt was discharged and less than 24 hrs later, pt presents in the er complaining of s.o.b.

physical assessment revealed:

[color=maroon]neuromuscular:[color=maroon] awake, alert and oriented x3, follows commands, speech clear, perrla, gait is unsteady, can ambulate to bedside commode with assistance.

[color=maroon]pulmonary[color=maroon]: decreased lung sounds bilaterally, breathing is shallow, and rapid, pleura vac with -20cm with serous sang. drainage

[color=maroon]cardiovascular:[color=maroon] regular hr and rhythm, peripheral pulses palpable, no edema, capillary refill wnl.

[color=maroon]psychosocial[color=maroon]: pt is agitated as she is in pain.

[color=maroon]gastroinestinal[color=maroon]: abdomen is soft on the left upper and lower quadrants, between the right upper and right lower quadrants, abdomen is found to be a bit firm; bowel sounds present in all 4 quadrants, no nausea, or vomiting, pt reported diarrhea yesterday.

[color=maroon]genitourinary:[color=maroon] pt voids in bedside commode, urine is pale yellow without sediment or blood

[color=maroon]integumentary[color=maroon]: skin is warm and intact, except for chest tube to right lateral- dressing is dry and intact

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[color=maroon]her bun was a little bit low (5) and i do not know how to explain that. could it be b/c she hasn't had a decent meal for awhile? or could it be the vanco??

i educated pt on use of incentive spirometer, and was in her room q 30 minutes, trying to coach her. she was unable make it move, but i guess it was better than her not doing it at all. can i put that under knowledge deficit or ineffective breathing pattern?

i would greatly appreciate any help that could be given.

thanks sooo much!!

[Passion4Caring]

ahhhhh...sorry didn't proofread before I posted...

[Daytonite, BSN, RN]

you mention that you "need more diagnoses". what have you diagnosed so far? i went through the data you posted and this was the abnormal data i came up with that i would use to determine the patient's nursing problems:

• decreased lung sounds bilaterally
  
• breathing is shallow and rapid
  
• unable make incentive spirometer move
  
• bun was 5
  
• pt reported diarrhea yesterday
  
• voids in bedside commode
  
• gait is unsteady
  
• 71 yrs old
  
• agitated as she is in pain
  
• an surgical wound somewhere?
  

every nursing diagnosis has a definition, related factors (causes) and defining characteristics (signs and symptoms). these can be found in a nursing diagnosis reference book, a currently published care plan book or the appendix of recent editions of taber's cyclopedic medical dictionary. you need to match the above symptoms with likely nursing diagnoses. part of diagnosing also includes looking up the pathophysiology as well as the signs, symptoms and complications of the patient's medical conditions (pneumothorax and mrsa). the chest tube and pleura-evac are medical treatments that, as nurses, we are often responsible for carrying out so we need to know how they are to be done, any complications connected with them and where they fit in with the nursing diagnoses and nursing care.

can i put that under knowledge deficit or ineffective breathing pattern?

yes, but how is it that you came to diagnose these? i found no evidence, or proof, of

deficient knowledge, specify

in the data that you posted. the fact that you taught the patient to use an incentive spirometer is not evidence that she didn't know how to use it to begin with. when writing a care plan everything must follow a step-by-step rational approach that pretty much tells a story of what has happened. first, assess. second, state the problem (diagnose). third, list strategies to do something about the problem (goals and nursing interventions).

[Passion4Caring]

hi, and sorry for getting back to you so late, so far i have:

[color=maroon]acute pain r/t chest tube insertion a.e.b. pt crying and stating she’s in pain, in addition to the pt demanding/begging for pain medication.

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[color=maroon][color=maroon]knowledge deficit r/t incentive spirometery a.e.b. pt verbalizing that she did not know what the purpose of the incentive spirometer was, or how to use it.

[color=maroon]impaired gas exchange r/t altered oxygen supply a.e.b rapid, shallow breathing and o2 saturation of 94%.

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[color=maroon][color=maroon]impaired mobility r/t pain from chest tube a.e.b. pt’s reluctance to attempt movement.