Please enable JavaScript.
Coggle requires JavaScript to display documents.
Dx: Shortness of Breath, **AI Recommendations (all edits in YELLOW…
Dx: Shortness of Breath
PMH
HTN, Bronchoostomy, Laryngeal Cancer, Lymphadema, hital henia, positive lymph node biopsy
Monitor for: impaired breathing mecahnics, SOB, fatigue, decreased activity dtolerance, impaired functional mobility
Approach/Intervention
Pulmonary interventions
breathing exercises, High Fowler positioning, monitor Spo2, energy conservation
Mobility
Bed Mobility, Transfer training, Ambulation Evaluation, Gait training, Functional Mobility training
monitor: fall risk, fatigue, dizziness
Strength/ Endurance
LE strengthening, Progressive endurance training
monitor: Fall Risk, fatigue
pt education
safety awareness, home safety, trach collar education, energy conservation strategies, breathing techniques
Lab Values
-
BMP
-
Blood glucose= HIGH
monitor for hyperflycemia: frequent urination, dehydration, fatigue, blurred vision, headache, fruity smelling breath (sign of ketoacidosis)
-
-
-
-
-
-
Considerations
emotional status
monitor for: anxiety, depression
-
-
Social/Home Environment
Considerations: single-story home, caregiver support from husband, married, retired
effect on discharge potential: improved due to less barriers in single-story home, caregiver availability
DVT/PE risk
monitor for DVT signs: LE swelling, pitting edema, calf pain
monitor for PE signs: SOB, bloody sputum, palpitations
-
Discharge Planning
goal: improve strength, stability, endurance to return home safetly
plan: improve ambulation, teach energy conservation strategies, implement home mobility availability, fit for assistive device, caregiver training, LE and UE strengthening.
Hx of present illness
Decreased activity due to : activity induced SOB, fatigue, reduced endurance, difficulty ambulating, decreased independence.
**AI Recommendations (all edits in YELLOW bubbles):
- AI recommended that I stated what specifically to monitor with worry of PE/DVT. I think this was important for the specificity of this assignment. I believe this would have been an oversight on my part if I did not put this in.
- AI recommended that I grouped all values of the BMP under 1 category instead of separately. I believe that this was a good insight for the organization of my mind map and made it more easily readible.
- AI reccomended what to watch out for regarding PMH. I decided to do this because I think it is wise to take the PMH into account and be aware if any past issues come into play during therapy
- AI's last recommendation was to add in discharge planning, which I forgot to include in this. I think this is essential for making patient goals that will make them independent and safe enough to go home. **