Scribd
Upload
576 views

Concept Map

1. The patient presented with respiratory distress, tachycardia, and abnormal blood gas results indicative of combined respiratory and metabolic alkalosis with hypoxia. Chest X-rays showed bilateral pleural effusions and pneumonia. 2. The patient was bedridden, dependent on others for care, and had developed bedsores. Nutritional status was compromised. 3. The patient had impaired communication due to a tracheostomy tube and was non-verbal. Multiple medical issues including infections, respiratory failure, and general weakness were reported.

Uploaded by

geejei
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
576 views

Concept Map

1. The patient presented with respiratory distress, tachycardia, and abnormal blood gas results indicative of combined respiratory and metabolic alkalosis with hypoxia. Chest X-rays showed bilateral pleural effusions and pneumonia. 2. The patient was bedridden, dependent on others for care, and had developed bedsores. Nutritional status was compromised. 3. The patient had impaired communication due to a tracheostomy tube and was non-verbal. Multiple medical issues including infections, respiratory failure, and general weakness were reported.

Uploaded by

geejei
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 4

Cardiopulmonary arrest 2o to severe

SUBJECTIVE: Daw nasakitan siya maginhawa as verbalized by the folks.

SUBJECTIVE: Nabudlayan nagid siya mag ginhawa kag nahapo siya as verbalized by folks. OBJECTIVE: 7/12/11 ABG Analysis revealed pAco2=87 pAO2= 65 HCO3= 48.8

Pneumonia with multiple metastases to Thyroid CA Other: HPN Stage 1 (Primary)

2o

OBJECTIVES: Restlessness Tachypnea (RR= 22-27 BPM) Tachycardia (123-134 bpm) Use of accessory muscles in breathing Presence of tracheostomy 7/12/2011 ABG Analysis revealed pAco2= 87 pAo2=65 Hco3=48.8 02 sat= 90% Combined respiratory and metabolic alkalosis with hypoxia 7/4/11 Chest Xray revealed Bilateral Pleural Effusion with regression Bilateral PNA with regression 7/5/11 thoracentesis aspirated 560 cc blood tinged

1.

Acute pain r/t accumulation of fluid in the pleural cavity.

Impaired gas exchange related to alveolar capillary membrane changes.

2.

02 Sat= 90% Combined respiratory and metabolic alkalosis with hypoxia Presence of tracheostomy tube O2 2lpm via T mask Absence of breath sounds upon auscultation Restlessness Gasping for air Tachycardia (RR= 123-134 bpm) Use of accessory muscle in breathing 7/4/11 Chest Xray revealed Bilateral Pleural Effusion with regression, Bilateral Pneumonia with regression and Bilateral Pulmonary nodules. 7/5/11 thoracentesis aspirated 560 cc blood tinged

Guarding behavior Facial grimace

SUBJECTIVE:

3.
OBJECTIVE: Restlessness. Presence of tracheostomy Tachypnea ( RR= 22-27 bpm) Use of accessory muscles in breathing Gasping of air O2 2 lpm via T mask 7/4/11 Chest X-ray revealed Bilateral Pleural Effusion with regression, Bilateral PNA with regression 7/12/11 ABG Analysis revealed O2 sat 90% PACO2=87 PaO2 65 Combined respiratory and metabolic alkalosis w/ hypoxia Presence of dirty white discharges upon suctioning Gasping for air

Ineffective airway clearance r/t presence of artificial airway.

Ineffective breathing pattern r/t decreased lung expansion secondary to accumulation of fluid in the pleural cavity.

Nabudlayan siya mag ginhawa kag ginahapo siya as verbalized by folks.

4.

OBJECTIVES: Restlessness Tachypnea (RR= 22-27 BPM) Tachycardia( 123-134 bpm)

Nutritional imbalance less than body requirements related to osterized tube feeding.

Use of accessory muscles Presence of tracheostomy O2 2lpm via T mask

7/12/11 ABG Analysis revealed


pAco2=87 pAO2= 65 HCO3= 48.8 02 Sat= 90% Combined respiratory and metabolic

5.
SUBJECTIVE: Naganiniwang siya as verbalized by folks OBJECTIVE: Height from 53 to 49 Weight from 44kg to 37 kg BMI= 17.61 (Underweight) Visible bony prominences: knees, ankles, chest, elbows, wrist, clavicle. Presence of NGT @ right nostrils OTF @ 1000 cal/day divided into 6 feedings 7/12/11 ABG Analysis revealed 02 Sat 90%(Hypoxia)

alkalosis with hypoxia 7/4/11 Chest Xray revealed Bilateral Pleural Effusion with regression, Bilateral Pneumonia with regression and Bilateral Pulmonary nodules. 7/5/11 thoracentesis aspirated 560 cc blood tinged Absence of breath sounds upon auscultation

7/5/11 thoracentesis aspirated 560 cc blood tinged

Presence of dirty white discharges upon suctioning.

SUBJECTIVE: GA TANGO NA SA. WALA NA SA GA SABAT as verbalized by the folks.

6.

Impaired Verbal Communication related to presence tracheostomy tube.

SUBJECTIVE: Indi na siya mapabay-an. Kinahanglan niya sang bulig sa tanan niya nga hulag as verbalized by folks. OBJECTIVE: 7/12/11 ABG Analysis revealed O2 sat 90% 7/12/11 Potassium 3.3mmol/L Dependent to SO and other healthcare provider in caring for herself

OBJECTIVES: Presence of tracheostomy tube. Weakness Unoriented Moderate Hypoxia as evidenced by ABG analysis of July 12, 2011, result is 90%. Tachypnea Inability to speak verbal language Absence of eye contact Unable to use facial or body expressions
Activity in tolerance r/t imbalance between oxygen supply and demand.

8.

Restlessness Bed ridden Presence of NGT @right nostrils Presence of tracheostomy 02 2 lpm via Tmask 7/4/11 Chest Xray revealed Bilateral Pleural Effusion with regression Tachypnea (RR= 20-27 bpm) Tachycardia( 123-134 bpm) Pupils are equally round but not reactive to light accommodation Unable to open eyes properly and spontaneously.

OBJECTIVES:

Muscles and joints are weak

7.
Presence of tracheostomy tube Use of NGT for feeding Dysphagia

Risk for aspiration r/t the presence of artificial airway opening in the trachea.

9.
SUBJECTIVE: Indi na siya mapabay-an. Kinahanglan niya sang bulig sa tanan niya nga ulubrahon as verbalized by the folks.

Self care deficit r/t body weakness

SUBJECTIVE: May samad siya gali sa likod as verbalized by folks.

OBJECTIVES: OBJECTIVE: Dependent to SO and other healthcare provider in caring for herself

Bed sores at the right lateral above the buttocks. Wrinkled skin Objective data: Bed-ridden Presence of tracheostomy 6/28/11 Hematology revealed WBC 12. 1 X 10 9/L 7/2/11 Bacteriology revealed Moderate growth of Pseudomonas Aeruginosa 7/4/11 Chest X-ray revealed Bilateral Pneumonia Presence of tracheostomy Capillary refill >3 seconds. Lips are dry and peeling.

Restlessness Bed ridden


Presence of bedsore @ the right lateral above the buttocks

Fatigue Untrimmed nails Presence of NGT @right nostrils Presence of tracheostomy


02 2 lpm via Tmask 7/12/11 ABG analysis revealed 02 sat= 90% hypoxia 7/4/11 Chest Xray revealed Bilateral Pleural Effusion with regression

10.

Bedsores @ right lateral above the buttocks.

Impaired skin integrity related to destruction of skin layers.

Tachypnea (RR= 20-27 bpm) Tachycardia( 123-134 bpm) Teeth are dirty white in color. Cavities noted on most of the teeth.

11.

Infection r/t presence of microorganisms and activation of inflammatory processes.

You might also like