TCC Nursing Program NUR 2564 Advanced Medical Surgical

Key Problem Risk for Infection

Concept Map
Why was the client admitted?

Key Problem Fluid Volume Excess

Supporting Data WBC count 15.33: Central line placed: currently septic: surgery yesterday to remove squamous cell carcinoma on chest wall: Currently Intubated: has indwelling Foley catheter Client Goal: Client will not acquire any further infections; WBC count will begin to normalize as patient responds to antibiotic therapy

Pt. Was life-flighted from outlying hospital where he was evaluated pH 7.2 & pCO2 of 60, CXR showing CHF, cardiomegaly, volume overload. Outlying hospital was not equipped to care for the pt.

Supporting Data: CXR indicating cardiomegaly with evidence of fluid volume overload, right mid lung edema; Lung sounds diminished bilaterally at the bases, edema present and patient looks generally puffy. BNP of 2547.5; Input exceeded output with a negative 1583ml Client Goal: Remain free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm

What is clients significant history and/or co-morbidities?

Key Problem Risk for Aspiration

HTN, CKD, bilat lung transplant 2004, hx of rejection & chronic host vs graft rejection. Hx of A-fib, CAD, stent placed in 2003, single vessel disease, squamous cell carcinoma on chest wall.
Has the client had any significant procedures/surgies during this admission?

Key Problem Decreased cardiac output

Supporting Data: Patient is currently intubated with endotracheal tube and is receiving supplemental nutrition via nasogastric tube

Pt. was intubated on arrival has stayed at the bedside.

Does the client have family? wife Other significant data: Patient

Supporting Data: Patient converted from a normal sinus rhythm to atrial fibrillation with RVR spontaneously in the night.

Client Goal: Swallow and digest nasogastric feeding without aspiration

converted from NSR in the 70-80bpm range to atrial fibrillation with RVR. Pt. was started on an IV drip of Heparin @ 30mL/hr. The pt. is immunosuppressed, currently septic, has fluid volume overload. My interpretation of the ABGs indicating partially compensated metabolic acidosis.

Client Goal: Remain free of side effects from the medications used to achieve adequate cardiac output

Key Problem: 2 Impaired Gas Exchange Supporting Data: Abnormal blood gasses; pCO231mm/Hg; pH 7.28; pO2 125 mm Hg; CO2 21; Lower extremities were blue-purple in color indicating poor perfusion; CXR indicating fluid volume overload and small bilateral pleural effusions. Client Goal: Demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for that client

Key Problem Risk for Electrolyte Imbalance

Supporting Data: evidence of fluid volume overload and the patient also has kidney disease; BUN 54; Creatinine 2.80; CA 7.9; Na 134; K 4.5; Phos 4.2; mag 2.4; Input exceeded output with a negative 1583mls Client Goal: Patient will attain normal serum potassium, sodium, calcium, and phosphorus