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Medical Dx: Post op right sided hemothorax - Coggle Diagram

- - - - CT results from ED found right sided pleural mass
        
        Pt presents in the ED with C/O of chest pain on exertion and SOB on 7/10/2023
        
        Came to visit daughter in the US.
        
        Social History: Lives in Nigeria
        
        Past Med Hx: HTN
- - - - Scheduled Medications:
        acetaminophen 650mg PO q6hrs for pain
        Classification: Analgesic
        Nursing consideration: Contraindicated if pt has liver or kidney disease.
        Lactulose solution 20g
        Classification: Laxative
        Nursing consideration: Monitor for signs of electrolyte imbalance, increased thirst, hunger, fatigue, and notify HCP.
        Mupirocin 2%
        Classification: Antibiotic
        Nursing consideration: Teach pt appropriate application.
        Oxycodone 5mg PO q4hrs for pain
        Classification: Opioid
        Nursing consideration: Monitor pain relief, respiratory rate, mental status, and bowel movements.
- - - - Goal: Patient will ambulate with assistance down the hallway at least once today.
        
        Evaluation: Goal was met. Pt ambulated to restroom, and to shower room keeping the chest tube chamber below chest level.
      - Teaching: Teach pt how to recognize and report any s/s of a DVT
    - - Collaborative intervention: Keep SBP under 140. Repeat CT scan shows signs of a clot formation in chest tubing. Anticipate tPA usage.
    - - Collaborative intervention: Encourage pt to use sequential compression device (SCD) to promote blood flow.
  - - - Goal: Pt will show no signs and symptoms of infection throughout my shift.
        
        Evaluation: Goal was met, pt continues to show no signs and symptoms of infections and WBC are decreasing.
      - Teaching: Teach pt about the importance of cough, deep breathing exercises, and frequent position changes.
    - - Interventions: Monitor vital signs and WBC for any change or signs or infections
        
        Collaborative interventions: Provide pt with heart healthy diet to promote recovery post surgery and manage HTN.
      - Collaborative interventions: Monitor chest tube chamber closer, making sure there is no air leak or kinks, document amount of blood drainage during your shift. Goal is for pt to have < 50mL of blood drain.