
Impaired Gas Exchange related to
decreased oxygen supply secondary to
bronchiectasis and atelectasis as
evidenced by:
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increased CO2 levels to 33
decreased respiratory rate to 4 bpm
need for mechanical ventilation
pale skin
dyspnea
restlessness
Nursing Diagnosis #1

Patient Goals:
◦ B.L.B will maintain a respiratory rate between
12-20 breaths per minute.
◦ B.L.B. will expectorate sputum and cough
effectively.
◦ B.L.B. will have normal breath sounds.
Nursing Diagnosis #1

Patient Interventions:
◦ Place B.L.B with the head of the bed elevated
to help facilitate chest expansion.
◦ Monitor B.L.B’s vital signs every hour to detect
tachypnea and tachycardia.
◦ Perform tracheostomy suctioning as needed to
help remove secretions.
◦ Change patient’s position every two hours to
mobilize secretions and allow aeration of lung
fields.
◦ Give bronchodilator medications at scheduled
times to dilate bronchioles and provide gas
exchange.
Nursing Diagnosis #1

Evaluation of Interventions: Goal Partially
Met
◦ Patient’s respiratory rate remained between
12-20 bpm for most of the day
◦ Patient maintained adequate oxygenation when
switched from spontaneous intermittent
mechanical ventilation to continuous positive
airway pressure.
◦ Patient did not experience dyspnea when
resting.
Nursing Diagnosis #1

Impaired Physical Mobility related to
pain and discomfort secondary to
hemiarthroplasty and right elbow
hardware removal and soft tissue repair
as evidenced by:
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Limited ROM in left leg and right arm
Difficulty turning
Slowed movement of upper extremities
Shortness of breath with turning and supine
postition
Nursing Diagnosis #2

Patient Goals
◦ B.L.B. will report a pain level between 0-3 on
numerical scale of 0-10.
◦ B.L.B. will perform range of motion with left
arm and right leg as much as possible.
◦ B.L.B. will have no shortness of breath with
turning.
Nursing Diagnosis #2

Patient Interventions:
◦ Monitor and document B.L.B.’s functional ability
throughout day to notice improvement and
decline in ability.
◦ Encourage patient to report pain or discomfort
and observe for nonverbal cues of pain to aide
in physical mobility.
◦ Implement ROM exercises every shift to
prevent contracture and muscle atrophy
◦ Reposition B.L.B. every two hours to prevent
skin breakdown
Nursing Diagnosis #2

Evaluation of Interventions: Goal Partially
Met
◦ Patient ‘s pain level remained below 3 for most
of the day
◦ Patient had increased mobility of left arm but
now right leg
◦ Patient did not display any evidence of
contractures or skin breakdown
Nursing Diagnosis #2

Risk for Infection related to surgical
incision secondary to hemiarthroplasty
right elbow hardware removal and soft
tissue repair, and neck mass biopsy
as evidenced by:
◦ Incision on left hip
◦ Incision under cast on right arm
◦ Incision on right side of neck
Nursing Diagnosis #3

Patient Goals:
◦ B.L.B’s vital signs will remain within normal
limits
◦ B.L.B.’s incisions will remain free from signs
and symptoms of infection
◦ B.L.B.’s will not have any dishescence
Nursing Diagnosis #3

Patient Interventions
◦ Wash hands before and after handling area
around wounds.
◦ Monitor dressing for intactness and drainage
◦ Use sterile techniques as needed for dressing
changes
◦ Monitor incisions for signs of infection, such as
redness, tenderness, and swelling.
◦ Monitor vital signs, especially temperature,
every hour.
Nursing Diagnosis #3

Evaluation of Interventions: Goal Met
◦ B.L.B.’s axillary temperature remained below
100˚F throughout day
◦ B.L.B’s incision site remained free from
erythema, edema, tenderness, warmth, and
purulent drainage.
◦ B.L.B’s wound edges remained approximated
with no evidence of dishescence.
Nursing Diagnosis #3