nursing diagnosis __intervention
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NURSING DIAGNOSIS & INTERVENTIONS
Esther Kamau
Interventions:
1. Monitor vital signs 2. Monitor breathing patterns and breath
sounds and for signs of respiratory impairment
3. Assess for tracheal deviation 4. Administer analgesics as prescribed for
pain management
5. Place in Fowler’s position for easy breathing
6. Administer oxygen as prescribed and humidification to moisten and loosen secretions
7. Provide respiratory treatments as prescribed
8. Administer bronchodilators and corticosteroids as prescribed to decrease bronchospasm, inflammation and edema
9. Provide a high-calorie, high protein , high vitamin diet
10. Provide activity as tolerated , rest periods, and active and passive range-of-motion exercises
11. Monitor for bleeding, infection and electrolyte imbalances
12. Monitor pulse oximetry
NON SURGICAL INTERVENTIONS
1. Radiation therapy: For localized intrathoracic lung cancers and for palliation of hemoptysis, obstructions, dysphagia and pain
2. Chemotherapy 3. Immunotherapy directed at enhancing
an effective immune response which favorably affects the course of the disease
SURGICAL INTERVENTIONS
1. Laser therapy: To relieve endobrachial obstruction
2. Thoracentesis and pleurodesis: To remove pleural fluid and relieve hypoxia
3. Thoracotomy with pneuomonectomy: Surgical removal of a lung
4. Thoracotomy with lobectomy: Surgical removal of one lobe of the lung for tumors confined to a single lobe
5. Thoracotomy with segmental resections: Surgical removal of a lobe segment with clients unable to tolerate lobectomy
PREOP INTERVENTIONS
Explain the potential post-op need for chest tubes
Note that closed chest drainage usually is not used for a pneuomonectomy, and the serum fluid that accumulates in the empty thoracic cavity eventually consolidates, preventing shifts of the mediastinum, heart and remaining lung
POST-OP INTERVENTIONS
Monitor vital signs Assess cardiac and respiratory status,
monitor for the absence and presence of lung sounds
Maintain chest tube drainage system, which will drain air and blood that accumulates in the pleural space
Assess chest tube insertion site for crepitus, (subcutaneous emphysema) and drainage
Administer O2 as prescribed Check physicians orders regarding client
positions; avoid complete lateral turning
Monitor pulse oximetry Provide activity as tolerated Encourage active range–of–motion
exercises of the operative shoulder as prescribed
Work Cited
Silvestri, L. A. (2005). Saunder’s comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier Saunders
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