Sarah Mind Map
 
 
 
 

Sarah - Mind Map

11 months ago by: cfox0413
 
 
Sarah Mindview
  • Shortness of breath
    • Psychosocial/cultural
      • 52 yo
      • Baptist church for 20 yrs; used to sing in choir
        • misses singing and going to church
        • attends when she feels up to it
        • church family visits infrequently
      • Retired postal worker w/ med insurance; husband deceased but left her financially well off
      • no regular physician
        • quick care when difficulty breathing
      • Daughter
        • lives in Florida
      • Son
        • lives on the west coast
      • brother - 65 yo
        • Lives an hour away
        • brittle diabetic
        • poor health, but will help when called
          • she doesn't like to bother him
      • smokes 2 packs/day for 40 yrs
      • Lives alone
        • Nursing Dx: risk for loneliness r/t social isolation
          • Nursing Intervention: The nurse will evaluate the client's desire for social interaction every day.
            • Client Outcome: The client will participate in substantive and meaningful activities that are ongoing and positive socially.
              • EBP: Nurses and other healthcare professionals must have an awareness of the client's social disconnectedness so they can offer assistance in making and maintaining social connections. (Dinkins, 2017)
            • Rationale:NI will allow the RN to understand how to best support client in returning to previous social interactions that client desires, such as choir and church.
    • Protective
      • Face flushed
      • Skin warm & dry
      • Temp 100.6 F
      • No edema
    • Sensory/Perceptual, Activity/Mobility, Comfort/Rest
      • Confused @ times
      • oriented to person, place, time
      • catnaps in daytime
      • Using sternocleidomastoid & abdominal muscles in breathing
        • leans forward when breathing
      • difficulty sleeping b/c of coughing
      • Lives alone & performs daily living activities alone, but rests frequently
        • Nursing Dx: Sleep deprivation r/t prolonged discomfort
          • Nursing Intervention: The RN will explore if daytime napping will supplement, rather than replace, nighttime sleep.
            • Client Outcome: The client will verbalize increased energy and less frequent rest.
            • Rationale: If the client's nighttime sleep pattern is regularly interrupted, an increase in daytime napping can alleviate sleep deprivation.
    • Fluid/gas -Cardiovascular
      • Blood glucose: 234 mg/dl
      • BP 156/88
      • ABG's: pH 7.45/pCO2 45/pHCO3 24
      • Pulse 94
      • HCT 39.0
      • HB 14.0
      • WBC 11,000
      • All peripheral pulses 3+
      • Creatinine .6
      • BUN 10
      • Na++ 140
      • Cl 106
      • K = 3.7
      • EKG - NSR
    • Nutritional/Metabolism
      • Wt 135
      • Ht 5'5"
      • Lost 25 lbs over last 18 months
      • Wine w/ evening meal
      • No appetite past week b/c of cold
      • drinks 4-5 glasses of water/day
      • tries to eat low fat meals 3x/day
        • tries to include fiber
      • doesn't cook for herself
    • Fluid/gas - Respiratory
      • history of chronic bronchitis
      • chronic cough w/ paroxysmal episodes
        • Can't clear throat
          • Nursing Dx: Ineffective airway clearance
            • Nursing intervention: The nurse will listen to breath sounds every 1-4 hours while the patient is in the hospital.
              • Client outcome: Client will maintain a patent airway at all times.
              • Rationale: Assessing breath sounds at regular intervals will alert the RN to acute changes during client's hospitalization.
      • bilateral wheezes w/ rales and rhonchi
      • coughs up thick, yellow secretions
      • shortness of breath
      • resp. rate 28/min
        • labored breathing
      • OTC bronchodilator "Primatene Mist" 3-4x/day
      • Has been told she will need oxygen @ home in future
      • x-ray shows infiltrate in lower lobes
      • has had bad cold for "about a week"
      • barrel shaped chest
      • Wakes frequently at night due to coughing
    • Growth & Dev.
      • Female
      • history of breast cancer
        • 10 years ago
        • treated via mastectomy and chemotherapy
    • Elimination/Urinary
    • Elimination/GI
      • Lips and mucous membranes pink
      • occasional constipation
        • remedied by eating prunes
      • abdomen soft, non-distended
      • bowel sounds present in all 4 quadrants
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