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Concept Map 2

The document summarizes the assessment and care of a patient with a pneumothorax who underwent chest tube insertion. Key findings included decreased oxygen saturation, respiratory distress, and chest pain. Interventions included monitoring vital signs closely after the procedure, assessing the chest tube drainage, maintaining the tube, managing pain, encouraging breathing exercises and coughing, and providing patient education on recovery. The expected outcomes were relief of symptoms and lung re-expansion as validated by imaging.

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3K views

Concept Map 2

The document summarizes the assessment and care of a patient with a pneumothorax who underwent chest tube insertion. Key findings included decreased oxygen saturation, respiratory distress, and chest pain. Interventions included monitoring vital signs closely after the procedure, assessing the chest tube drainage, maintaining the tube, managing pain, encouraging breathing exercises and coughing, and providing patient education on recovery. The expected outcomes were relief of symptoms and lung re-expansion as validated by imaging.

Uploaded by

lanrevoice
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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2. Acute Pain r/t traumatic surgery Data Support: Patient rates pain as 5/10 on pain scale, grimaces.

Interventions: Assess pain level. Ask to describe pain and triggers. Ask client to identify a comfort function goal on a self report pain tool. Assess facial expressions and behaviors. Prevent pain during procedures. Administer opioids orally or intravenously. Review clients flow sheet and MAR. Teach and implement nonpharmacological interventions

Concept Mapping for Pneumothorax

Ineffective Breathing Pattern Data Support: O2 sat low 90s, RR 22 sternotomy incision and pain Interventions: Monitor respiratory rate, depth and ease of respiration. Note pattern. Note use of accessory muscles, nasal flaring, irritability or confusion. Observe color of tongue, skin. Monitor Oxygen saturation. Determine severity of dyspnea. Support client in using pursed-lip and controlled breathing techniques. Position client in upright or semi fowlers position. Administer oxygen as needed. Increase clients activity to three times a day or as tolerated. Encourage deep breathing and coughing.

Assessment: Baseline cardiopulmonary status including vs (145/86, RR: 22, O2 sat: 90% HR: 101) SOB, cyanosis, anxiety, absent of breath sound on affected side, crackles noted adjacent to affected areas, sudden sharp focal chest pain , muffled heart sound ,vein neck distention and bruises, open chest wound, asymmetric chest movement

Monitoring/Care/intervention After insertion, monitor vital signs Q15 X2, Q30min X2. Q1hr X4. Monitor amount/type of drainage by marking drainage level on outside of the collection chamber Q1hr. Report drainage greater than 100ml/hr or changes in characteristics of drainage Assess patient drainage for air leaks Maintain drainage free of loops Assess insertion and surrounding site for inflammation and infection. Monitor pain and intervene as necessary

Chief Medical Diagnosis: Pneumothorax SOB, Pain Priority Assessments: VS (RR 22, O2: 90%),

Patient Teaching Explain the procedure, the indication for the chest tube insertion and how the closed chest drainage system works Keep patient in semi fowlers position Instruct patient to turn Q2hr, to promote drainage Instruct patient to engage in coughing and deep breathing exercise and splinting the affected side to reduce complication. Encourage passive or active ROM of the arm in the affected side Instruct patient and family about activity prescribed while maintain the drainage system below the level of chest

Expected Outcomes

Knowledge Deficit
- Importance of Deep breath cough and use of incentive spirometer - The signs of infection -To assess pain -Teach about Medication (administration and side-effects,) - -Practice ROM exercises to build strength and increase ambulation

Removal of air, fluid or blood from the chest cavity Fluctuation or tidaling noted in water chamber seal until lungs is expanded Relief of respiratory distress Re-expansion of collapsed lungs, validated by chest radiography Effective respiratory rate, rhythm and depth of respiration

5. Activity intolerance Interventions: Determine cause of intolerance. When appropriate increase activity allowing the client to assist with positioning and transfers. Perform ROM exercise and decrease the amount of time spent in bed. Allow patient time to relief self from sitting. Assess for constipation. Provide emotional support and encouragement. Use a gait walking belt when ambulating.

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