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This Concept Map, created with IHMC CmapTools, has information related to: acute zwerner, Health Care Need: Lung Re-expansion Medical Diagnosis: Pneumothorax Key Assessments: 1. Vital Signs 2. Pain Level 3. Respiratory Status 4. Oxygen Saturation 5. ABG's 6. Chest Tube Assessment Pathophysiology: Rupture of a bleb on the lung surface allows air to enter pleural space from airways. Manifestations: Abrupt onset Pleuritic chest pain Dyspnea, Shortness of breath Tachypnea, tachycardia unequal lung excursion Decreased breath sounds on affected side., Can Lead to: ????, Health Care Need: Lung Re-expansion Medical Diagnosis: Pneumothorax Key Assessments: 1. Vital Signs 2. Pain Level 3. Respiratory Status 4. Oxygen Saturation 5. ABG's 6. Chest Tube Assessment Pathophysiology: Rupture of a bleb on the lung surface allows air to enter pleural space from airways. Key Problem: Altered ABG's Nursing Diagnosis: Impaired Gas Exchange related to pneumothorax as evidenced by altered ABG's and decreased lung capacity. Data: Pt presented with severe dyspnea, tachypnea, and chest pain. RR: 40, Chest Pain 8/10, Spo2: 94% on 4l nc ABG: pH: 7.25, pCo2: 75, HCO3: 32, PO2, 72, BE: 3.3 Interventions: Assess Mental Status Assess breathing pattern and respiratory rate Assess use of accessory muscles Pulmonary Function Evaluation SPO2 status Turn every 2 hours Elevate head of bed Monitor oxygen PRN Encourage ambulation Medications: Oxygen, Normal Saline, Morphine Outcomes: Gas exchange will not be compromised as evidenced by the following: Improved cognitive status, PaO2, PaCO2, arterial pH, and O2 saturation, within normal limits. No dyspnea at rest. Minimal dyspnea with exertion. Normal respiratory rate, rhythm, depth of inspiration., Manifestations: Abrupt onset Pleuritic chest pain Dyspnea, Shortness of breath Tachypnea, tachycardia unequal lung excursion Decreased breath sounds on affected side. POTENTIAL NURSING DIAGNOSES RISK FOR: INFECTION DECREASED MOBILITY IMPAIRED SKIN INTEGRITY PAIN SOCIAL ISOLATION INEFFECTIVE COPING ACTIVITY INTOLERANCE DISTURBED BODY IMAGE CAREGIVER ROLE STRAIN CONFUSING COPING FALLS FATIGUE FEAR KNOWLEDGE DEFICIENT NONCOMPLIANCE (SMOKING) SELF-CARE DEFICIT SLEEP DEPRIVATION INEFFECTIVE TISSUE PERFUSION: PULMONARY, Health Care Need: Lung Re-expansion Medical Diagnosis: Pneumothorax Key Assessments: 1. Vital Signs 2. Pain Level 3. Respiratory Status 4. Oxygen Saturation 5. ABG's 6. Chest Tube Assessment Pathophysiology: Rupture of a bleb on the lung surface allows air to enter pleural space from airways. Key Problem: Impaired Respiratory Status (Failure) Nursing Diagnosis: Ineffective breathing pattern related to pneumothorax as evidenced by tachypnea, dyspnea, unequal lung excursion, and decreased breath sounds in right lung fields. Data: Pt presented with severe dyspnea, tachypnea, and chest pain RR: 40,Pain: 8/10 ABG: pH: 7.25,pCo2: 75,HCO3: 32 Po2: 72,BE: 3.3 Interventions: Auscultation of breath sounds for adventious or absent Chest Tube Insertion, Encourage Deep Breathing, Splint chest when cough or position changes, oxygen PRN, Continuous Spo2, Reposition patient to maximize ventilation. Medications: Normal Saline, Morphine, Oxygen Outcomes: Normal respiratory rate, depth, and rhythm. ABG's and or SPO2 normal limits for this pt. Bilateral chest excursion. No dyspnea. Depth of inspiration and ease of breathing normal. Demonstrates uncomprimised respiratory status as evidenced by not using accessory muscles, minimal adventitious breath sounds and decreased dyspnea., Manifestations: Abrupt onset Pleuritic chest pain Dyspnea, Shortness of breath Tachypnea, tachycardia unequal lung excursion Decreased breath sounds on affected side. POTENTIAL NURSING DIAGNOSES RISK FOR: INFECTION DECREASED MOBILITY IMPAIRED SKIN INTEGRITY PAIN SOCIAL ISOLATION INEFFECTIVE COPING ACTIVITY INTOLERANCE DISTURBED BODY IMAGE CAREGIVER ROLE STRAIN CONFUSING COPING FALLS FATIGUE FEAR KNOWLEDGE DEFICIENT NONCOMPLIANCE (SMOKING) SELF-CARE DEFICIT SLEEP DEPRIVATION INEFFECTIVE TISSUE PERFUSION: PULMONARY Randi Zwerner, RN Indiana State University Acute Concept Map: PNEUMOTHORAX