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Sarah - Mind Map
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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