r fluid in lung. Doenges, p. 164Pt Respirations rate at 24 and shallow2. Demonstrate / help patient learn to perform coughing, e g., splinting chest and effective coughing while in upright position.Deep breathing facilitates maximum expansion of the lung’s smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces chest discomfort, and an upright position favors deeper, more forceful cough effort.Pt. Demonstrated splinting procedures when demonstrating proper use of incentive spirometer as noted in NDX # 13. Suction as indicated. Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffec- tive cough or decreased level of consciousness. Pt stated “ I can do this myself” when offered assistance. Pt used yager device effectively.4. Force fluids to at least 2500 ml / d (unless contraindicated). Offer warm, rather than cold, fluids. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions. Pt I & O noted @ 225 ml urine between 08:30 and 13:30. Pt drank 250 ml at breakfast. Poor skin tugor and dry skin noted.NDX #2. Con’t OUTCOME/GOAL STATEMENT: .Short Term: Pt. Will continue to use oral suction to relieve mucous build up. . Pt will show no signs of cyanosis. Pt will demonstrate patent airway with breath sounds clearing. Pt will drink 2500 ml qd. Long Term: Pt’s skin turgor will improve by increasing fluid intake. Doenges p. 164#3. NURSING DIAGNOSIS: Pain, chest related to surgical incision, (tissue trauma) and physical factors (chest tube insertion-) AEB Pt reporting pain at insertion site of 6 on a 1-10 scale when moved. Doenges, p. 190Intervention /ActionRationalesEvaluation / Outcome Criteria1. Assess for presence of pain (verbal and nonverbal): rate pain on scale of ( 1-10)Use of rating scale aids patient in assess- ing level of pain and provides tool f...
