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This Concept Map, created with IHMC CmapTools, has information related to: 10-20-09, 72 yr old WF Assessment Allergies - aspirin; VS: BP 149/67, HR 62, O2 97, Temp. 36.7 oral, RR 18; Rt UA PICC INT, no edema or redness; bruises on LA for past IV's; tolerating PICC well; AAO X 3; UE5+ strength, LE 3/4+ strength; calm, clear speech, PERRLA, EOM +; strong, reg. rhythm; warm skin with good color, dry; pink nailbeds, cap. refill ɛ WT 55.2 kg; LE edema 0-1+; pulses: rad. 3+ bilat, dors. ped. 4+ bilat; has PM; reg. respirations, lung sounds: rt - clear in all fields, lt - cl LUL & LML but slight crackles in LLL; BNC @2L humidified; Full CPR status; soft abdomen, bowel sounds active X 4 quaduarants; CDiff neg.; TED hose on both feet; reports feeling like her feet are going to "pop", redness and swelling have developed over the past two weeks heels occasionally start to turn purple; doctor's aren't sure what is wrong with her feet; pt in good spirits but ready to go home. reported that she was "so depressed" when she found out she wasn't going home today., Ineffective airway clearance r/t excessive mucus, retained secretions secondary to COPD AEB non-productive cough, LLL expiratory crackles that clear with cough. Goal #2 Patient will demonstrate effective coughing and clear breath sounds before discharge from the hospital., Patient will remain free of any evidence of new bleeding by discharge from the hospital. Evaluation Goal met. Patient should know signs of bleeding while in the hospital., 72 yr old WF History CHF, HTN, COPD, PPM, asperigillosis (last 18 months), 72 yr old WF Nsg Dx #3 Risk for Powerlessness r/t illness, elevated blood pressure, and circulation problems of unknown origin preventing her from going home., Ineffective protection r/t abnormal blood profiles and drug therapy secondary to aspergillosis infection AEB RBC 3.46↓, HGB 10.1↓, HCT 30.8↓, WBC 19.9↑. Based on Allergies - aspirin; VS: BP 149/67, HR 62, O2 97, Temp. 36.7 oral, RR 18; Rt UA PICC INT, no edema or redness; bruises on LA for past IV's; tolerating PICC well; AAO X 3; UE5+ strength, LE 3/4+ strength; calm, clear speech, PERRLA, EOM +; strong, reg. rhythm; warm skin with good color, dry; pink nailbeds, cap. refill ɛ WT 55.2 kg; LE edema 0-1+; pulses: rad. 3+ bilat, dors. ped. 4+ bilat; has PM; reg. respirations, lung sounds: rt - clear in all fields, lt - cl LUL & LML but slight crackles in LLL; BNC @2L humidified; Full CPR status; soft abdomen, bowel sounds active X 4 quaduarants; CDiff neg.; TED hose on both feet; reports feeling like her feet are going to "pop", redness and swelling have developed over the past two weeks heels occasionally start to turn purple; doctor's aren't sure what is wrong with her feet; pt in good spirits but ready to go home. reported that she was "so depressed" when she found out she wasn't going home today., Ineffective protection r/t abnormal blood profiles and drug therapy secondary to aspergillosis infection AEB RBC 3.46↓, HGB 10.1↓, HCT 30.8↓, WBC 19.9↑. Goal #2 Patient will remain free of any evidence of new bleeding by discharge from the hospital., 1. Take vital signs q1 to 4 hrs 2. Observe nutritional status. 3. Monitor for any reports of fever, chills, or new onset pain. 4. Help the client to bathe daily. 5. Help to turn, cough and deep breathe daily. 6. Promote activity as tolerated. 7. Watch for continued hemoptysis 8. Watch for changes associated with fluid volume loss. After completion Goal met. Patient should know signs of bleeding while in the hospital., Patient will relate methods to enhance secretion removal by the end of my shift today. Evaluation Goal met. Patient was able to cough sputum several times before the end of my shift. Continue with interventions, Ineffective airway clearance r/t excessive mucus, retained secretions secondary to COPD AEB non-productive cough, LLL expiratory crackles that clear with cough. Goal #1 Patient will relate methods to enhance secretion removal by the end of my shift today., 72 yr old WF General Teaching 1. Patient was taught about the mediation Gauifenesin,what it is used for and why she needs to continue to take it. 2. Patient was taught about the importance of drinking fluids, especially water, to not only help with her symptoms but to also help the Gauifenesin work properly., Risk for Powerlessness r/t illness, elevated blood pressure, and circulation problems of unknown origin preventing her from going home. Based on Allergies - aspirin; VS: BP 149/67, HR 62, O2 97, Temp. 36.7 oral, RR 18; Rt UA PICC INT, no edema or redness; bruises on LA for past IV's; tolerating PICC well; AAO X 3; UE5+ strength, LE 3/4+ strength; calm, clear speech, PERRLA, EOM +; strong, reg. rhythm; warm skin with good color, dry; pink nailbeds, cap. refill ɛ WT 55.2 kg; LE edema 0-1+; pulses: rad. 3+ bilat, dors. ped. 4+ bilat; has PM; reg. respirations, lung sounds: rt - clear in all fields, lt - cl LUL & LML but slight crackles in LLL; BNC @2L humidified; Full CPR status; soft abdomen, bowel sounds active X 4 quaduarants; CDiff neg.; TED hose on both feet; reports feeling like her feet are going to "pop", redness and swelling have developed over the past two weeks heels occasionally start to turn purple; doctor's aren't sure what is wrong with her feet; pt in good spirits but ready to go home. reported that she was "so depressed" when she found out she wasn't going home today., 72 yr old WF Nsg Dx #2 Ineffective protection r/t abnormal blood profiles and drug therapy secondary to aspergillosis infection AEB RBC 3.46↓, HGB 10.1↓, HCT 30.8↓, WBC 19.9↑., Patient will demonstrate effective coughing and clear breath sounds before discharge from the hospital. To accomplish 1. Auscultate breath sounds q1 to 4 hours 2. Monitor respiratory rate. 3. Position the patient to optimize respiration 4. Help the patient to deep breathe and perform controlled coughing. 5. Encourage to use the incentive spirometer. 6. Assist with clearing secretions from pharynx by offering tissues. 7. Encourage activity and ambulation as tolerated. 8. Encourage fluid intake., Allergies - aspirin; VS: BP 149/67, HR 62, O2 97, Temp. 36.7 oral, RR 18; Rt UA PICC INT, no edema or redness; bruises on LA for past IV's; tolerating PICC well; AAO X 3; UE5+ strength, LE 3/4+ strength; calm, clear speech, PERRLA, EOM +; strong, reg. rhythm; warm skin with good color, dry; pink nailbeds, cap. refill ɛ WT 55.2 kg; LE edema 0-1+; pulses: rad. 3+ bilat, dors. ped. 4+ bilat; has PM; reg. respirations, lung sounds: rt - clear in all fields, lt - cl LUL & LML but slight crackles in LLL; BNC @2L humidified; Full CPR status; soft abdomen, bowel sounds active X 4 quaduarants; CDiff neg.; TED hose on both feet; reports feeling like her feet are going to "pop", redness and swelling have developed over the past two weeks heels occasionally start to turn purple; doctor's aren't sure what is wrong with her feet; pt in good spirits but ready to go home. reported that she was "so depressed" when she found out she wasn't going home today. Medications gabapentin (Neurontin), guaifensin (Robitussin), hydrocortisone topical (Proctozone), lactobacillus acidophilis (Flora-Q), levothyroxine (Synthroid), metoprolol (Lopressor), nitroglycerin ointment, sulfamethoxazole- trimethoprim (Septra DS), brinzolamide opthalmic (Azopt)., 72 yr old WF Diagnosed with Chest pain, Hemptysis, Patient will remain free of new infection during my shift today. To accomplish 1. Take vital signs q1 to 4 hrs 2. Observe nutritional status. 3. Monitor for any reports of fever, chills, or new onset pain. 4. Help the client to bathe daily. 5. Help to turn, cough and deep breathe daily. 6. Promote activity as tolerated. 7. Watch for continued hemoptysis 8. Watch for changes associated with fluid volume loss., 72 yr old WF Nsg Dx #1 Ineffective airway clearance r/t excessive mucus, retained secretions secondary to COPD AEB non-productive cough, LLL expiratory crackles that clear with cough., 1. Auscultate breath sounds q1 to 4 hours 2. Monitor respiratory rate. 3. Position the patient to optimize respiration 4. Help the patient to deep breathe and perform controlled coughing. 5. Encourage to use the incentive spirometer. 6. Assist with clearing secretions from pharynx by offering tissues. 7. Encourage activity and ambulation as tolerated. 8. Encourage fluid intake. After completion Goal met. Patient was able to demonstrate deep breathing and controlled coughing before discharge from the hospital., 1. Take vital signs q1 to 4 hrs 2. Observe nutritional status. 3. Monitor for any reports of fever, chills, or new onset pain. 4. Help the client to bathe daily. 5. Help to turn, cough and deep breathe daily. 6. Promote activity as tolerated. 7. Watch for continued hemoptysis 8. Watch for changes associated with fluid volume loss. After completion Goal met. Patient showed no signs of new infection during my shift.