5/20/13

CONCEPT MAP

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CONCEPT MAP
CONCEPT MAP: Pneumohemothorax secondary to Gunshot Wound

Bullet

Wound debridement and suturing

Bullet penetrated at right upper chest wall and its vascular network

Possible entry of microorganisms to the wound

CBC: WBC - 11.5 / 5-10 x 10g/L

Lung tissue and its vascular network injury

Monitor V/S every 4 hours

Possible infection

Risk for infection

Blood effuses from damaged blood vessels to the pleural cavity

Assess ctt patency and respiratory status Assess for oscillation Assess the color, amount of the output

Air enters to the pleural cavity through the penetrated chest wall

Initiation of inflammatory immune response

Cefugen 750 mg IVTT every 8 hours

Hemothorax

Chest X-ray

Pneumothorax

Pleuritic and musculoskeletal pain

Tramadol hydrochloride 10mg slow IV as rescue analgesic Dolfenal 500mg 1 tab TID

Fluid compresses lung

Dyspnea RR: 26

Positive pressure compresses lung

Difficulty using intercostals muscles

Inefective breathing pattern Tramadol hydrochloride 10mg slow IV as rescue analgesic Dolfenal 500mg 1 tab TID Cefugen 750 mg IVTT every 8 hours CBC: WBC - 11.5 / 5-10 x 10g/L

Decrease lung expansion

Dyspnea RR: 26

Chest thoracostomy tube inserted at right upper chest

Ventilation-perfusion mismatching

Legend:
Acute pain Risk for infection Hypoxia Ineffective Airway clearance Ventolin 1 neb every 8 hours & Robittusin Pulse Oximetry O2 sat: 90% Oxygen inhalation at 2L/minutes CBC hemoglobin: 113.0 Hypoxemia / 130 160g/L
Pathogenesis Nursing Care Plans Diagnostic Test Factor Nursing Management Clinical Manifestations

Medical/Surgical Management

Medication

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