Patient Information and History

Clinical Mind Map

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Patient Information and History by Mind Map: Patient Information and History

1. 78 y/o Male

2. Respiratory Failure, COPD, CHF, HTN, Aortic Stenosis, Biventricular Failure

3. Medications

3.1. Apixaban, Rosuvastatin, Prednisone, Azithromycin, Indacaterol, Furosemide, Metoprolol, Ceftriaxone, Salbutamol, Ipratropium

4. Report

4.1. Foley Catheter, 3.5 L Oxygen via Nasal Cannula, Last B.M 3 days ago, Gross edema to legs, IV Meds (Furosemide, Azithromycin, Ceftriaxone)

5. Respiratory Failure (Hypercapnia)

5.1. Pathophysiology

5.1.1. Occurs due to pump failure because of either mechanical defects, CNS depression, or an imbalance of energy demand and supply. The body is continuously retaining carbon dioxide as there is a significant reduction of alveolar ventilation. (1)

5.2. Risk Factors

5.2.1. Lung diseases (COPD, Pneumonia, ARDS), Damage to tissues and ribs surrounding lungs, Muscular dystrophy, Drug/Alcohol Overdose, Stroke (2)

5.3. Manifestations

5.3.1. SOB, Low SpO2, Rapid Breathing, Cyanosis, Confusion/Anxiety, Fatigue, Arrhythmias, Cough/Wheeze, Headaches (3)

6. Nursing Diagnosis

6.1. Impaired gas exchange, R/T respiratory failure. (4)

6.1.1. Interventions

6.1.1.1. Maintain pt. airway, Provide supplementary oxygen as required and maintain oxygen administration as ordered, Ensure pt is in optimal position (semi-fowlers), Provide oral and nasal care, Cluster care to decrease oxygen demands, Monitor vitals and obtain labs, Encourage assist with ADLs and ambulation, Encourage slow deep breathing (insentive spirometer), Provide reassurance and reduce anxieties, Limit pt. exposure to people with respiratory infections (5)

7. Desired Outcome

7.1. Remove excess CO2, and restore O2 levels

8. Resources

8.1. (1)

8.1.1. https://erj.ersjournals.com/content/22/47_suppl/3s%C2%A0

8.2. (2)

8.2.1. https://www.nhlbi.nih.gov/health-topics/respiratory-failure

8.3. (3)

8.3.1. https://www.healthline.com/health/chronic-respiratory-failure#symptoms

8.4. (4)

8.4.1. http://fnm.tums.ac.ir/userfiles/education/en/pediatrics/Student/3.pdf

8.5. (5)

8.5.1. https://nurseslabs.com/impaired-gas-exchange/