Clinical Mindmap

Get Started. It's Free
or sign up with your email address
Clinical Mindmap by Mind Map: Clinical Mindmap

1. Top 3 client problems:

1.1. Impaired urinary secretion

1.2. Impaired skin integrity

1.3. Ineffective breathing pattern

2. 39 Y/O White, Male, 5’10” 148lbs. FULL CODE. Admitted with Pleural Effusion with planned Thoracentesis. History and Diagnosis’ of: Thyroid disease, Tachycardia, HTN, Heart Disease, ESRD, CAD, Stroke, COPD, CHF, Osteoarthritis Surgical/ Procedures: General GI surgery, Cystectomy, Suprapubic Nephrostomy Tube Placement, Thoracentesis most recently 8/23/18 Allergies: Latex, Sulfa products, Adhesives (Can use office tape), Morphine. Date of Care: 9/26/18 5th Tower Patient has Masters of History degree: has high learning capacity

2.1. Ineffective breathing pattern R/T Left side Pleural Effusion

2.1.1. Goal: Have recognize benefits of using incentive spirometer to keep airways open and lungs inflated. Result: client did not perform action but explained understanding of process and benefits.

2.1.2. Nursing interventions: 1. Encourage client to ambulate unit once per hour when awake. 2. Monitor O2 levels and apply oxygen prn. 3. Provide an incentive spirometer and instruct client to use every 10 minutes when awake while deep breathing and coughing. 4. Keep HOB elevated 30 degrees or higher at all times. 5. Monitor Strict I&O to assess for “lost fluid” as it may build up in chest cavity.

2.1.3. Meds: Cefazolin for surgical prophylaxis

2.1.4. Labs and diagnostics: CO2- 17.0 (23.0-29.0) O2 sat 94-97

2.1.5. Objective & Subjective Data: Right lung is clear with no adventitious breathing. Left lung is diminished in the lower lobe. Coarse crackles throughout. Pt states no difficulty breathing or sputum. X-ray reveals large volume of fluid in thoracic cavity. Breathing rate is 17 with equal rise and fall bilaterally. Pt has “double breaths” often. Pt states no prior lung issues until recently.

2.1.6. Potential Complications: Infection, Difficulty breathing, Lung collapse, Atelectasis, Tracheal Deviation, Pneumothorax, sepsis, respiratory failure, death.

2.1.7. Risk Factors: Inflammation, Epidermolysis Bullosa, infection

2.1.8. Multidisciplinary Care: Dr’s Kwan, Hakin, Fuller, and Sinha. Dialysis nurses and staff, Unit nurses, Physical Therapy, Dietary, Case management team, respiratory therapy.

2.1.9. Surgical Interventions: Thoracentesis most recently 8/23/18 (2300 mL drained) with another planned within 24 hours.

2.1.10. Client Education & Discharge Planning: Instruct client on ways to help prevent respiratory infection, early s&s of respiratory infection, deep breathing and coughing, when to seek healthcare, and what to do in the event of a collapsed lung. Have client follow up with pulmonologist.

2.2. Impaired skin integrity r/t Epidermolysis Bullosa

2.2.1. Goal: Have client Identify 5 activities in daily routine that add risk for infection/ harm to skin by next shift. Result: client was lethargic and sleepy after dialysis and did not see need in waking him

2.2.2. Lab & Diagnostics: All labs done on 9/24/18 BNP- 2746.4 (<100) RDW- 17.3 (11.5- 14.5) RBC- 3.32 (4.7- 6.1) K+ - 6.6 (3.5- 5.0) Albumin- 3.3 (3.5- 5.5) Vitamin D- 8.4 (30.0- 100.0)

2.2.3. Potential Complications: Infection, Insensible fluid loss, Increased renal strain, Impaired body image, risk for social withdrawal, excessive potassium release, hyperkalemia, arrhythmias, dehydration, increased nutrient need.

2.2.4. Objective & Subjective Data: He has many open sores due to his disorder that he’s had since birth. Many wounds are closed and show signs of healing. Some wounds are still open. No tunneling. Wounds are all superficial. Wounds spread all over body and not confined to a specific area. Patient states that he has always been very careful with his body, because he knows that he has an extra delicate situation that can react very quickly to negative factors. Patient demonstrates good understanding of his condition and how to manage it.

2.2.5. Risk Factors: Impaired renal function, Chronic skin condition, Left sided jugular IV, Clotted AV graft in left arm, clubbed nails

2.2.6. Multidisciplinary Care: Dr’s Kwan, Hakin, Fuller, and Sinha. Dialysis nurses and staff, Unit nurses, Physical Therapy, Dietary, Case management team, wound care nurse.

2.2.7. Multidisciplinary Care: Dr’s Kwan, Hakin, Fuller, and Sinha. Dialysis nurses and staff, Unit nurses, Physical Therapy, Dietary, Case management team, wound care nurse.

2.2.8. Client Education & Discharge Planning: Increase client education of how to maintain skin rigidity and prevent infection. Educate on additional nutrient intake required for this patient. Educate patient about regulating body fluids so as not to overload the body, but not to get dehydrated either.

2.2.9. Medications: B Complex Vitamin C-Folic Acid PO QD Hydroxyzine (Atarax) 25 Mg Tab Q6H PRN for itching. Hydrocodone- Acetaminophen (Norco 10-325mg) PRN Q4H for pain for skin irritation

2.2.10. Nursing Interventions: 1. Monitor skin for signs of infection 2. Monitor weight daily before breakfast and keep a log 3. Provide teaching about appropriate foods for renal diet 4. Document progress of existing wounds and document new wounds. 5. Encourage ambulation and frequent repositioning.

2.3. Impaired urinary excretion r/t Cystectomy (Medical error)

2.3.1. Goal: Have client verbalize s&s of urinary skin breakdown Result: client verbalized S&S of skin breakdown due to urine

2.3.2. Lab & Diagnostics: Dialysis 3X weekly. 3000 mL of fluid removed September 25th and 2200mL removed September 26th Labs conducted on 9/24/18 RBC, UA >20 (<4) WBC, UA >25 (<5) Glucose UA - Trace (Negative) Blood, UA - 2+ (Negative) Leukocytes, UA - 3+ (Negative) Bacteria, UA - 1-9 (<1) Calcium- 8.1 (9-11) BUN- 100 (7-20) EGFR- 5.4 (>60)

2.3.3. Objective & Subjective Data: Prior to Dialysis patient had bp of 149/109, HR of 101, and a temp of 99.1. During Dialysis pt had vitals of bp 101/63, HR of 99, and temp of 96.5. After Dialysis pt was lethargic and had bp of 123/81, HR of 95, and temp of 97.2. Weight 72.4 kg prior to dialysis and 69.5 kg after. Patient reports pain of 7/10 in his neck near new dialysis cath upon movement. Patient began dialysis in January of 2018 and stated he “felt depressed about it for a couple of months,” but he showed effective coping mechanisms. Pt stated, “I just started trying to find small things in nature to make me happy.” pt is avid hiker and finds peace in nature. Pt states his relationship with God helped him overcome depression with situation and give him strength to face future challenges because he knows he can overcome it and he wants to be able to get back to the life he had.

2.3.4. Potential Complications: Hematuria, UTI, Nephrostomy bag leakage, Nephrostomy tube comprositation, Sepsis, Kidney failure, death.

2.3.5. Risk Factors: Dietary factors, environmental factors, addition body system failure.

2.3.6. Multidisciplinary Care: Dr’s Kwan, Hakin, Fuller, and Sinha. Dialysis nurses and staff, Unit nurses, Physical Therapy, Dietary, Case management team, Social worker, home health

2.3.7. Surgical Interventions: Inadvertent cystectomy 1986 contributing to condition

2.3.8. Client Education & Discharge Planning: Instruct client on different characteristics of urine and when to consult a physician or visit the ED. Ensure client understands to continue dialysis.

2.3.9. Medications: sevelamer carbonate to control phosphorus level, Diltiazem for HTN, Metoprolol for HTN, Clonidine (Catapres) tab 0.1 Mg PO QD for HTN

2.3.10. Nursing Interventions: 1. Maintain strict I&O 2. Perform skin assessment to protect against skin break down. 3. Ensure that nephrostomy tubes are not compromised 4. Ensure patient has sufficient knowledge of nephrostomy hygiene 5. Monitor urine for changes in color, odor, and frequency.