new_1st_page_of_concept_map-nrg_prces-with_instructions
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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