ll impedes ability to interact with others.N/AHospital environment and routines may affect alertness.Pain, chest related to biologic factors (tissue trauma) and physjcal factors (chest tube insertion- sertion) AEB Pt reporting pain at insertion site of 6 on a 1-10 scale when moved(Actual)Neurosensory IntegrationAbility to move around and/or sit with friends and family is very important to client.Chronic lung disease makes it difficult for sustained mobility.Sustained physical activity impaired due to low O2 levels influence sexual activities.Bed rest until chest tube is out. Ineffective Airway Clearance R/T decreased flexibility of lung tissue AEB fungal infection of lungs, chest tube, fluid presence (Actual)MobilityDoenges, 1993 LIST OF NURSING DIAGNOSIS.1. Ineffective breathing pattern related to decreased lung expansion secondary to pus in the pleural space AEB asymmetrical chest expansion and decreased breath sounds over affected area. (Combination of Doenges p.197 and Tucker p.304 Patient Care Standard for Thoracic Empyema)2. Ineffective Airway Clearance R/T decreased flexibility of lung tissue AEB fungal infection of lungs, chest tube, fluid presence . Doenges, p. 1643.Pain, chest related to biologic factors (tissue trauma) and physjcal factors (chest tube insertion- sertion) AEB Pt reporting pain at insertion site of 6 on a 1-10 scale when moved4. Nutrition altered, less than body requirements R/TMalnutrition/infection/ AEB poor food intake, weight loss. Doenges p.5. Self care deficit R/T physical limitations, and frustration over loss of independence AEB in ability to maintain cleanliness of tube insertion site( right posterior chest), changing clothes Doenges , p. 3836.Impaired social inter-action R/T inability to sustain prolonged activity AEB SOB, and use of continual O2. (Actual)7.Risk for impaired skin integrity R/T immobility, mechanical pressure & sheer, NIDDM. AEB reddened area on coccyx. (Potential)8.Risk for fl...
