2.

Ineffective Airway
Clearance/ Breathing
Pattern/Gas Exchange
-pleural effusion
-rt lower lobe lung sounds
diminished anterior and
posterior
-crackles in rt lower lobe
anterior and posterior
-respiration rate 20
-labored breathing
-uneven rise and fall of chest
-long time smoker
-Continuous O2 monitoring
-O2 saturation level above 95%
-chest x-ray, fluid in rt pleura
l space
-thoracentesis, 500 cc aspirated

3.Risk for DVT

-Prolonged bed rest
-Thoracentesis incision
-Long time smoker
-Heart and lung complications
-Old age
-Compression stockings
-Compression device
-heparin
-passive ROM exercises

1. Decrease Cardiac Output

-Atrial fibrillation
-CHF
-Cardio myopathy
-Coronary Artery Disease
-VS q4h
-Digoxin
-Metoprolol
-Amiodarone
-Apical HR 88
- BP 90/60 post procedure (after
administration of metoprolol)
-SBP in 120s pre-procedure

Chief Medical Diagnosis:

Pleural Effusions/ Post-Op
Thoracentesis

8. Immobility
-amputation of all left toes
-amputation of right first toe
-loss of sensation in both lower
extremities
-activity level guarded (bed
bound, all side rails up)
-fall precautions
- lethargic (post-procedure)

7. Acute Pain
-right first toe amputation wound
-thoracentesis incision
-pain rating 4 out 10 post procedure
-prn acetaminophen (not administered
during shift)

Priority Assessments:
Breath sounds, breathing patterns,

4. Altered Mental Status

- dementia
-oriented x2 (person, place)
-Made a few inappropriate
comments
-Namenda
-Forgetfulness
-Didnt recall agreeing to do
undergo a thoracentesis

5. Risk for Unstable Blood

Glucose
-Diabetes Mellitus Type II
-Insulin glargine
-Insulin aspart
- NPO since midnight

6. Risk for
Bleeding/infection
-right first toe
cellulitis/amputation
(surgery in September,
wrapped in acrylic bandage)
-pleural effusions
-thoracentesis incision
-pleural effusion
-piperacillin/tazobactam
-vancomycin
-history of sepsis