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This Concept Map, created with IHMC CmapTools, has information related to: Hemothorax, Key Problem #__2___ Sharp chest pain to the right side ND: Pain, Acute DATA: -Patient complaining of sharp pain in right side of chest -CXR showed right hemothorax -Minor cuts and bruises on both lower extremities from accident Vitals: T 98.0, P 102, resp. 24, O2 sat 87% Outcomes: -Patient will have pain of less than 4/10 at the next shift assessment(short term) . -Patient wull have pain of 0/10 at time of discharge(long term) Interventions: -Assess reports of pain, including location, duration, and intensity (scale of 0-10) every 2 hours and prn(Doenges, Moorhouse, & Murr, 2009). -Observe for non-verbal pain cues -Explore non-pharmacologic pain relief measures ex. yoga, meditation, distraction, guided imagery -Administer pain medications as indicated by the physician -Monitor vital signs for changes that may occur due to unrelieved pain -Reasssess pain 15 minutes after a nursing intervention is completed to monitor effectiveness of intervention. -Plan activities during peak analgesic effect(Doenges, Moorhouse, & Murr, 2009) Is related to Key Problem #_3____ Risk for injury with new chest tube ND: Risk for Injury DATA: -Due to right hemothorax, the patient has a chest tube to the right side. Outcomes -Patient will verbalize understanding of using the nurse call bell when needing to get up with chest tube after the nurse's explanation(short term). -Patient will have no injuries resulting from chest tube by the time of discharge(long term). Interventions: -Review with client the purpose/function of chest drainage unit, taking note of safety features(Doenges, Moorhouse, & Murr, 2006). -Secure tubing connection sites -Secure drainage unit to patient's bed or on a stand in a low traffic area (Doenges, Moorhouse, & Murr) -Instruct patient to use nurse call bell to get assistance when they need to get up. -Observe for signs of respiratory distress indicating that a hemothorax may have reoccured or worsened., Medical Diagnosis: Hemothorax-Escape of blood into the thoracic cavity because of an injury to the chest that damages vessels in the thoracic cavity(Falvo, 2009). Key Assessments: Pain Assessment Vital Signs with O2 Saturations Chest Tube Falls Integumentary ???? Key Problem #__2___ Sharp chest pain to the right side ND: Pain, Acute DATA: -Patient complaining of sharp pain in right side of chest -CXR showed right hemothorax -Minor cuts and bruises on both lower extremities from accident Vitals: T 98.0, P 102, resp. 24, O2 sat 87% Outcomes: -Patient will have pain of less than 4/10 at the next shift assessment(short term) . -Patient wull have pain of 0/10 at time of discharge(long term) Interventions: -Assess reports of pain, including location, duration, and intensity (scale of 0-10) every 2 hours and prn(Doenges, Moorhouse, & Murr, 2009). -Observe for non-verbal pain cues -Explore non-pharmacologic pain relief measures ex. yoga, meditation, distraction, guided imagery -Administer pain medications as indicated by the physician -Monitor vital signs for changes that may occur due to unrelieved pain -Reasssess pain 15 minutes after a nursing intervention is completed to monitor effectiveness of intervention. -Plan activities during peak analgesic effect(Doenges, Moorhouse, & Murr, 2009), Medical Diagnosis: Hemothorax-Escape of blood into the thoracic cavity because of an injury to the chest that damages vessels in the thoracic cavity(Falvo, 2009). Key Assessments: Pain Assessment Vital Signs with O2 Saturations Chest Tube Falls Integumentary Patient Information Patients Initials: D.S. Gender:Male Age: 28 years old Weight: 188 lbs History: smoker for 10 years, s/p accident after being hit while he was on his motorcycle. The motorcycle pulled in front of a car on the interstate and the car hit the bike knocking off the patient. The patient tested negative for any drugs or alcohol. The patient was acknowledged as being the cause of the accident. Upon being brought into the ER, the patient complained of sharp chest pain on the right side. His vitals upon arrival to the ER were:T 98.0, pulse 102, resp. 24, O2 sat 87%. A stat chest x-ray was done and showed a right hemothorax. The patient complained of SOB at rest. A chest tube was placed on the right side and the patient has been admitted to a med/surg unit for observation. D.S. suffered only scrapes and bruises to his lower extremities other than the hemothorax. The patient states he lives alone in his apartment. He has a girlfriend of 6 months. His parents are both alive and living locally. He has one older brother and one older sister that live locally., Medical Diagnosis: Hemothorax-Escape of blood into the thoracic cavity because of an injury to the chest that damages vessels in the thoracic cavity(Falvo, 2009). Key Assessments: Pain Assessment Vital Signs with O2 Saturations Chest Tube Falls Integumentary ???? Key Problem #__1___ O2 Saturation at 87%, shortness of breath ND: Tissue Perfusion, altered Impaired Gas Exchange Breathing Pattern, ineffective DATA: -Vitals: T 98.0, pulse 102, resp. 24, O2 sat 87% -Stat CXR showed a right hemothorax -Patient complaining of SOB at rest -Chest tube placed on right side Outcomes: -Patient will have O2 saturation of 92% or above at the next shift assessment (short term) -Patient will have no shortness of breath upon discharge (long term) Interventions: -Conduct respiratory assessments(auscultating breath sounds) every 2 hours -Assess vital signs every 4 hours and prn -Assess chest tube drainage system every 4 hours, also noting drainage amount and characteristics. -Administer supplemental oxygen via cannula as needed (Doenges, Moorhouse, & Murr, 2006) -Monitor ABG's, pulse oximetry , and chest x-rays as they are ordered per the MD. -Observe for signs of respiratory distress indicating that a hemothorax may have reoccured or worsened., Key Problem #_3____ Risk for injury with new chest tube ND: Risk for Injury DATA: -Due to right hemothorax, the patient has a chest tube to the right side. Outcomes -Patient will verbalize understanding of using the nurse call bell when needing to get up with chest tube after the nurse's explanation(short term). -Patient will have no injuries resulting from chest tube by the time of discharge(long term). Interventions: -Review with client the purpose/function of chest drainage unit, taking note of safety features(Doenges, Moorhouse, & Murr, 2006). -Secure tubing connection sites -Secure drainage unit to patient's bed or on a stand in a low traffic area (Doenges, Moorhouse, & Murr) -Instruct patient to use nurse call bell to get assistance when they need to get up. -Observe for signs of respiratory distress indicating that a hemothorax may have reoccured or worsened. Medical Diagnosis: Hemothorax-Escape of blood into the thoracic cavity because of an injury to the chest that damages vessels in the thoracic cavity(Falvo, 2009). Key Assessments: Pain Assessment Vital Signs with O2 Saturations Chest Tube Falls Integumentary, Key Problem #__1___ O2 Saturation at 87%, shortness of breath ND: Tissue Perfusion, altered Impaired Gas Exchange Breathing Pattern, ineffective DATA: -Vitals: T 98.0, pulse 102, resp. 24, O2 sat 87% -Stat CXR showed a right hemothorax -Patient complaining of SOB at rest -Chest tube placed on right side Outcomes: -Patient will have O2 saturation of 92% or above at the next shift assessment (short term) -Patient will have no shortness of breath upon discharge (long term) Interventions: -Conduct respiratory assessments(auscultating breath sounds) every 2 hours -Assess vital signs every 4 hours and prn -Assess chest tube drainage system every 4 hours, also noting drainage amount and characteristics. -Administer supplemental oxygen via cannula as needed (Doenges, Moorhouse, & Murr, 2006) -Monitor ABG's, pulse oximetry , and chest x-rays as they are ordered per the MD. -Observe for signs of respiratory distress indicating that a hemothorax may have reoccured or worsened. ???? 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