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Concept Map Pleural Effusion

This patient has multiple medical issues putting them at risk for infection, imbalanced fluid volume, decreased cardiac output, and activity intolerance. Specific risks include ineffective airway clearance due to cough and low oxygen levels; hyperkalemia from fluid volume imbalance; atrial fibrillation exacerbating congestive heart failure; and digoxin toxicity causing fatigue and dysrhythmias. The priority is to monitor oxygen saturation, lung sounds, vital signs, and digoxin levels while treating the infection, managing fluids and electrolytes, reducing cardiac risk factors, and gradually increasing activity.

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2K views1 page

Concept Map Pleural Effusion

This patient has multiple medical issues putting them at risk for infection, imbalanced fluid volume, decreased cardiac output, and activity intolerance. Specific risks include ineffective airway clearance due to cough and low oxygen levels; hyperkalemia from fluid volume imbalance; atrial fibrillation exacerbating congestive heart failure; and digoxin toxicity causing fatigue and dysrhythmias. The priority is to monitor oxygen saturation, lung sounds, vital signs, and digoxin levels while treating the infection, managing fluids and electrolytes, reducing cardiac risk factors, and gradually increasing activity.

Uploaded by

api-341263362
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Decrease Cardiac

Risk for Infection: Ineffective Airway Output:


Temp = 100.5F, warm skin, Clearance: Atrial Fibrillation
slow healing wound Cough, dyspnea, low saturation CHF exacerbation
Diabetic/hyperlipidemia level Chronic coronary artery
VS, CBC, Incentive spirometer, sitting disease
IV antibiotic, Tylenol, cooling upright Ischemic Cardiomyopathy
measures, atorvastatin, Oxygen as prescribed Family hx of cardiac
lispro insulin disease
Vitals q4h
Permanent pacemaker
Coronary By Pass Graft
Risk for Imbalanced fluid Graft Mitral Valve
volume: Chief Medical Diagnosis: Aspirin, Carvedilol,
Hyperkalemia: weakness, Hypoxia secondary to Left Digoxin, Losartan
abdominal distention, Pleural Effusion
dysrhythmias, heart block, Priority Assessment:
asystole Oxygen saturation level,
Infusion Hydration, restrict pain, lung sounds, pain,
Risk for Poisoning (Digoxin
fluid intake, Spironolactone, chest expansion, cough,
toxicity):
Lasix vital signs
Fatigue, dysrhythmias, visual
Daily weights, lab/electrolytes
disturbances, anorexia
values
Hold medication & notify the
Pain: physician
Pleurisy, chest pain, abdominal Digoxin level, K+, Ca+, Mg+,
pain BUN/Cr, LF test
Morphine, Tylenol, anti-angina Activity Intolerance:
medication Fatigue, shortness of breath with
Chest xray, Ultra sound or CT activity, generalized weakness,
Thoracentesis with US guide chest pain
Fluid Transudate Stool softener to avoid Valsava
More invasive (chronic/recurrent): maneuver
pleurodesis, pleuroperitoneal shunt Bedrest, gradual increase of activity
Urinal and bedpan at bedside
Incentive Spirometer, VS monitoring

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