5/20/13 CONCEPT MAP

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Assess ctt

patency and

respiratory

status

Assess for

oscillation

Assess the

color, amount

of the output

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

Wound debridement and

suturing

Bullet penetrated at right upper chest

wall and it’s vascular network

Lung tissue and it’s vascular

network injury

Monitor V/S every

4 hours

Blood effuses from damaged blood

vessels to the pleural cavity

Hemothorax Chest X-ray

Fluid compresses lung Dyspnea RR: 26

Air enters to the pleural cavity

through the penetrated chest wall

Pneumothorax

Positive pressure

compresses lung

Possible entry of microorganisms to

the wound

Possible infection

Initiation of inflammatory

immune response

Pleuritic and

musculoskeletal pain

Difficulty using

intercostals muscles

Inefective breathing patternDecrease lung expansion Dyspnea RR: 26

Chest thoracostomy tube

inserted at right upper chest Ventilation-perfusion mismatching

CBC: WBC - 11.5 / 5-10

x 10g/L

Risk for infection

Cefugen 750 mg

IVTT every 8 hours

Tramadol

hydrochloride 10mg

slow IV as rescue

analgesic

Dolfenal 500mg 1 tab

TID

Legend:

Acute painCBC hemoglobin: 113.0

FactorPathogenesisHypoxemia / 130 – 160g/L

Risk for infection Nursing ManagementNursing Care Plans

Hypoxia Pulse Oximetry Oxygen inhalation

O2 sat: 90% at 2L/minutes Diagnostic Test Clinical ManifestationsIneffective Airway clearance

Ventolin 1 neb every Medical/Surgical Management Medication

8 hours & Robittusin

CONCEPT MAP

CONCEPT MAP: Pneumohemothorax secondary to Gunshot Wound

Bullet

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