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This Concept Map, created with IHMC CmapTools, has information related to: B_SNAPP_Complex MED Surg_Cmap 1, V. Expected Outcomes 1. The patient will demonstrate improved ventilation and adequate oxygenation aeb blood gas levels within normal parameters such as his O2 sat within 95-100% by 1300 on 11/6/09. 2. The patient will not experience SOA while sitting up on the side of his bed aeb tolerating sitting up for longer periods of time by 1300 on 11/6/09. 3. The patient will maintain clear lung sounds aeb no crackles or wheezes by 1300 on 11/6/09. 4.The patient will remain free of signs of respiratory distress aeb not using accessory muscles when breathing by 1300 on 11/06/09. 5. The patient will verbalize understanding of oxygen supplementation aeb not wanting to remove his NC and verbalizing why he is on oxygen by 1300 on 11/6/09. Interventions & Rationals VI. Interventions 1. The nurse will administer humidified oxygen per NC as prescribed by physician by 0600 on 11/6/09 and will monitor placement in nares q2h. 2. The nurse will assess respiratory status, including depth, rate, effort, and lung sounds q2h starting at 0700 on 11/6/09. 3.The nurse will monitor the client's behavior and mental status for the onset of restlessness, agitation, and confusion q2h starting at 0700 or anytime in contact with the patient on 11/6/09. 4. The nurse will monitor oxygen saturation continuously by pulse oximetry on 11/6/09. 5. The nurse will observe for cyanosis of the skin q2h starting at 0700 on 11/6/09 especailly note color of the tongue and oral mucous membranes. (Lemone & Burke 2009), III. Focused Assessment 1. VS HR 64, O2 94%, Temp 97.7, Resp 22, Pulse 65, and B/P 123/69 2. O2 stat dropped to 87% with minimal movement such as being moved up in bed. 3. Became SOA while just sitting up on the side of his bed. 4. 2 L of oxygen by NC 5. Rapid, shallow breathing ranging about 24 breathes per minute at rest. 6.Needed bed at 45 degree angle to help him breathe. When bed was flat it was hard for him to breathe. Generate Nursing Diagnosis IV. Priority Nursing Diagnosis Impaired gas exchange r/t altered blood flow to alveoli aeb O2 stat dropping to 87% with minimal movement. Define: Excess or deficit in oxygenation or carbon dioxide elimination at the Alveolar-capillary membrane (Wilkenson & Ahern 2009), III. Focused Assessment 1. VS HR 64, O2 94%, Temp 97.7, Resp 22, Pulse 65, and B/P 123/69 2. O2 stat dropped to 87% with minimal movement such as being moved up in bed. 3. Became SOA while just sitting up on the side of his bed. 4. 2 L of oxygen by NC 5. Rapid, shallow breathing ranging about 24 breathes per minute at rest. 6.Needed bed at 45 degree angle to help him breathe. When bed was flat it was hard for him to breathe. Generate Nursing Diagnosis IV. Secondary Nursing Diagnosis 2. Pain r/t decreased oxygen exchange in right lung aeb grimacing and guarding his RUQ Define: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. 3. Ineffective Protection r/t altered clotting function from anticoagulant therapy. Define: Decrease in ability to guard self from internal or external threats such as illness or injury. 4. Activity Intolerance r/t acute pain aeb grimacing with movement. Define: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. (Wilkenson & Ahern 2009), I.Patients Info & Medical Diagnosis R.D. age 62 year old white male Medical Di:agnosis: 1. Pulmonary Embolism 2. RUQ Pain assess III. Focused Assessment 1. VS HR 64, O2 94%, Temp 97.7, Resp 22, Pulse 65, and B/P 123/69 2. O2 stat dropped to 87% with minimal movement such as being moved up in bed. 3. Became SOA while just sitting up on the side of his bed. 4. 2 L of oxygen by NC 5. Rapid, shallow breathing ranging about 24 breathes per minute at rest. 6.Needed bed at 45 degree angle to help him breathe. When bed was flat it was hard for him to breathe., III. Focused Assessment 1. VS HR 64, O2 94%, Temp 97.7, Resp 22, Pulse 65, and B/P 123/69 2. O2 stat dropped to 87% with minimal movement such as being moved up in bed. 3. Became SOA while just sitting up on the side of his bed. 4. 2 L of oxygen by NC 5. Rapid, shallow breathing ranging about 24 breathes per minute at rest. 6.Needed bed at 45 degree angle to help him breathe. When bed was flat it was hard for him to breathe. III III. Abnormal Assessment Findings 1. RUQ Pain w/ guarding 2. RBC 3.94 (Low), HGB 11.8 (Low), HCT 36.1 (Low), 3. Blood Sugar 120 (High) 4. Medications: Lovenox SQ 120 mg, Lasix IV 40 mg, K-Dur ( Potassium Chloride Tablets) 1x10 MEQ PO w/ breakfast. 5. History of Cough, Chest Pain, and Thrombi in Leg 6. Breakfast 0%, Lunch 25% 7. 0800 pain 3/10 w/ pain medication given 30 min. prior 8. 1200 pain 9/10 w/ pain medication give after that finding, V. Expected Outcomes 1. The patient will demonstrate improved ventilation and adequate oxygenation aeb blood gas levels within normal parameters such as his O2 sat within 95-100% by 1300 on 11/6/09. 2. The patient will not experience SOA while sitting up on the side of his bed aeb tolerating sitting up for longer periods of time by 1300 on 11/6/09. 3. The patient will maintain clear lung sounds aeb no crackles or wheezes by 1300 on 11/6/09. 4.The patient will remain free of signs of respiratory distress aeb not using accessory muscles when breathing by 1300 on 11/06/09. 5. The patient will verbalize understanding of oxygen supplementation aeb not wanting to remove his NC and verbalizing why he is on oxygen by 1300 on 11/6/09. Evaluation VII. Evaluation of expected Outcomes 1. The patient demonstrated improved ventilation and adequate oxygenation aeb O2 stat at 97% by 1300 on 11/6/09. Goal Met. 2. The patient did not experience SOA while sitting up on the side of his bed aeb stating better tolerance to sitting up and being able to sit up for a longer period of time by 1300 on 11/6/09 Goal Met. 3.The patient maintained clear lung sounds aeb no crackles or wheezes heard during ausciltation by 1300 on 11/6/09 Goal Met. 4. The patient remained free of signs of respiratory distress aeb not using accessory muscle by 1300 on 11/6/09 Goal Met. 5.The patient verbalized understanding of the need for his oxygen and did not attempt to remove it and he explained understanding of why he was on oxygen by 1300 on 11/6/09. Goal Met., II. Pathophysiology 1.Pulmonary Embolismn(PE) is obstruction of blood flow in the pulmonary vascular system by an embolus. 2. PE usually is due do to a thrombus; tumors, fat, amniotic fluid, and debris may also become emboli. 3.PE affects both perfusion and ventilation: 1. Bronchospasm occurs in the affected area of lung. 2. Dead space increases. 3. Alveolar surfactant decreases, increasing the risk for atelectasis. (Lemone & Burke, 2008) leads to III. Focused Assessment 1. VS HR 64, O2 94%, Temp 97.7, Resp 22, Pulse 65, and B/P 123/69 2. O2 stat dropped to 87% with minimal movement such as being moved up in bed. 3. Became SOA while just sitting up on the side of his bed. 4. 2 L of oxygen by NC 5. Rapid, shallow breathing ranging about 24 breathes per minute at rest. 6.Needed bed at 45 degree angle to help him breathe. When bed was flat it was hard for him to breathe., IV. Secondary Nursing Diagnosis 2. Pain r/t decreased oxygen exchange in right lung aeb grimacing and guarding his RUQ Define: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months. 3. Ineffective Protection r/t altered clotting function from anticoagulant therapy. Define: Decrease in ability to guard self from internal or external threats such as illness or injury. 4. Activity Intolerance r/t acute pain aeb grimacing with movement. Define: Insufficient physiological or psychological energy to endure or complete required or desired daily activities. (Wilkenson & Ahern 2009) Prioritized to IV. Priority Nursing Diagnosis Impaired gas exchange r/t altered blood flow to alveoli aeb O2 stat dropping to 87% with minimal movement. Define: Excess or deficit in oxygenation or carbon dioxide elimination at the Alveolar-capillary membrane (Wilkenson & Ahern 2009), IV. Priority Nursing Diagnosis Impaired gas exchange r/t altered blood flow to alveoli aeb O2 stat dropping to 87% with minimal movement. Define: Excess or deficit in oxygenation or carbon dioxide elimination at the Alveolar-capillary membrane (Wilkenson & Ahern 2009) Expected Outcomes V. Expected Outcomes 1. The patient will demonstrate improved ventilation and adequate oxygenation aeb blood gas levels within normal parameters such as his O2 sat within 95-100% by 1300 on 11/6/09. 2. The patient will not experience SOA while sitting up on the side of his bed aeb tolerating sitting up for longer periods of time by 1300 on 11/6/09. 3. The patient will maintain clear lung sounds aeb no crackles or wheezes by 1300 on 11/6/09. 4.The patient will remain free of signs of respiratory distress aeb not using accessory muscles when breathing by 1300 on 11/06/09. 5. The patient will verbalize understanding of oxygen supplementation aeb not wanting to remove his NC and verbalizing why he is on oxygen by 1300 on 11/6/09., I.Patients Info & Medical Diagnosis R.D. age 62 year old white male Medical Di:agnosis: 1. Pulmonary Embolism 2. RUQ Pain affects II. Pathophysiology 1.Pulmonary Embolismn(PE) is obstruction of blood flow in the pulmonary vascular system by an embolus. 2. PE usually is due do to a thrombus; tumors, fat, amniotic fluid, and debris may also become emboli. 3.PE affects both perfusion and ventilation: 1. Bronchospasm occurs in the affected area of lung. 2. Dead space increases. 3. Alveolar surfactant decreases, increasing the risk for atelectasis. (Lemone & Burke, 2008), VI. Rationals 1. Humidified oxygen prevents the nares from becoming dry and the oxygen being prescribed helps with proper gas exchange when placement is not interruppted. 2. Increased respiratory rate, use of accessory muscles, nasal flaring, and abdominal breathing may be seen with hypoxia. 3. Changes in behavior and mental status can be early signs of impaired gas exchange. 4. An oxygen saturation of less than 90% indicates significant oxygenation problems. 5. Central cyanosis of the tongue and the oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may or may not be serious. ???? VI. Interventions 1. The nurse will administer humidified oxygen per NC as prescribed by physician by 0600 on 11/6/09 and will monitor placement in nares q2h. 2. The nurse will assess respiratory status, including depth, rate, effort, and lung sounds q2h starting at 0700 on 11/6/09. 3.The nurse will monitor the client's behavior and mental status for the onset of restlessness, agitation, and confusion q2h starting at 0700 or anytime in contact with the patient on 11/6/09. 4. The nurse will monitor oxygen saturation continuously by pulse oximetry on 11/6/09. 5. The nurse will observe for cyanosis of the skin q2h starting at 0700 on 11/6/09 especailly note color of the tongue and oral mucous membranes. (Lemone & Burke 2009)