LovinNursing

Well first of all THANK YOU THANK YOU THANK YOU. This is my first time posting here so I wasn't really sure what all I should put down. My patient had a low temp (97.1)- the room temp was 78 and the pt. was warm, normal pulse - 87, Systolic was a little high (157/73 at noon up from 123/57 at 7AM over ), pulse ox, 98% and respirations 16. The patient does have a nasal cannula turned to 3L of O2 sitting beside her bed (the nurse said it was for her on an as needed basis) . THe pt. didn't use it at all. The nurse said the pt. is noncompliant and that is why the pt. is in sich bad shape. The pt. also suffers from Type II Diabetes Mellitus, Hypertension, Anemia (these are the other medical diagnosis )> THe pt. is 60 with a weight of 273 On Assessment, tthe pt. was A & O x's 4. The Pt. suffers from glaucoma, but has no corrective devices. No edema, except at the wound site on the pts. right side. Peripheral pulses present though the right side was diminshed. Neck veins were extended with a bounding pulse and cap. refill Now Labs: RBC 3.39L Hg 9.2L Hct 27.7L WBC 13.1H MCHC 33.1L K+ 2.7L Ca++ 8.5L (pharmacy had it flagged but is norm in all books) Albumin 1.9L CO2 34H Glucose 162H ALT 25L Platelets 698H My nursing Dx: Impaired gas exchange r/t Increased levels of CO2 a/w pneumothorax Ineffective tissue perfusion r/t decreased arterial blood flow a/w pneumothorax Acute pain r/t inflammation of tissues and prostaglandin release a/w right minithoracatomy and decortication of lung Impaired tissue perfusion r/t decreased Hg concentrationin blood a/w anemia Impaired skin integrity r/t impaired metabolic state and physical immobilization a/w diabetes mellitus noncompliance r/t patients value system a/w hypertension meds the pt is taking: Avandia, Diphenhydramine HCL, Effexor, Enalapril, Ferrous sulfate, Heparin SQ, Ibuprofren, Indapamide, Klor Con, Lidocaine, Linezolid, Lovostatin, Metoprolol, Novolin R, Protonix, Zofran, Docusate sodium, Morphine sulfate. Percocet, Nitroglycerin The wound is infected with MRSA and staph, it is red, tender, swollen and very warm. Serous drainage, yellow/green.

What would be my related to?? I know the associated with but this semester we have to do the related to at a cellular level

Ok my school no longer allows infection or risk for infection. My patient went into the hospital to get an infusaport so she could begin chemotherapy. When they put the infusaport in they nicked her lung causing a pneumothorax. She had chest tubes put in and then had a minithoracatomy and decortication as well as removal of a blood clot. The main reason she is still in the hospital is because she has infection in the healing wound. There is no longer any evidence of a pneumothrorax. The wound tested positive for MRSA and Staph. She has been in the hospital for almost a month and the chemotherapy has been delayed because of the infection. What nursing diagnosis can I give to express this finding?? HELP me please! And THANK YOU In advance!