new_1st_page_of_concept_map-nrg_prces-with_instructions

8/7/2019 NEW_1st_page_of_concept_map-Nrg_Prces-with_instructions

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•Major medical diagnosis: Respiratory

Distress, PNA

•Relevant past medical history: For past

2wks pt has had URI S&S of cough, runny nose, &

nasal congestion. 11/16/10 developed wheezing &

SOB. 6/10/10 admitted in respiratory failure

hypotension & rt PNA. X-ray: Rt infiltrate. 6/10-

6/15 intubated. Hx: PNA. Gestational age:30wks

•History of this hospitalization: Pt presentsto hospital w/ SOB & wheezing.

•Expected Signs & SymptomsRapid shallow breathing, *retractions, gruntingsounds, *flaring of the nostrils, apnea

•Highest priority NANDAIneffective airway clearance R/T inflammation &

 presence of secretion AEB wheezing, retractions, &nasal congestion

 Orem’s Self Care Requisite: Air 

wholly compensatory

•Goal statement-Patient will have an improvement

in respiratory function AEB decreaseuse of accessory muscles and adecrease in amount of secretions by

the end of the shift.

• Evaluation- Goal was met AEB reduction of retraction & when suctioned there was a

decreased amount of secretions.

Contributing Factors: Albuterol tx, position change, forced fluids, O2 NC .25% &

suctioning 

LABS  Pt’s lab’sWBC 4-10 13.8RBC 4.2-5.9 4.78HCT 37-48% 39.6HGB 12-16 13.1MCV 80-95 82.8MCH 27-31 27.5MCHC 32-36 33.2Platelets: presence of clumping

  Neutro 54-75% 28

Lymph 10-20% 61Mono 2-8% 1

Eos 1-4% 4  NA 135-145 138

K 3.5-5.0 4.0CL 100-106 105

CO2 24-30 20.8BUN 8-25 <5

CR 0.3-0.6 0.3Blood cultures: pendingx-ray: bilateral PNA

MEDS*Albuterol,Bronchodilator 2.5mg, inhalation,q4hrs/q2hrs PRNSOB, wheezing

TREATMENTS-Albuterol tx w/Respiratory Therapist-Position change q2hrs- Suction as indicated- Force fluids- Nasal Canula .25%

•Initials: M.B.

•Age: 7mos f •Culture/ethnicity: Asian

•Religion: Christian•Occupation: n/a

•Developmental stages (Erickson Developmental): Trust vs.mistrust: Pt displays trust knowing that all her caring needs will

 be met AEB comfort, feeding, & stimulation.

•Environmental factors: Physical: Pt’s room is @ room temp,

it is safe and free of any environmental hazards, pt is in crib w/

side rails up. Social: Pt’s mother is present in the room. Pt has

one older sibling, and is often swaddled by mother. Cultural &

Spiritual: Pt’s mother states that she attends church