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Concept Map Level 4

Shift report: 3/8/06: Jane Doe female admitted 3/6/06 through the ER. Dx of vomiting, Hyponatremia (low serum sodium concentration) and prerenal azotemia (Prerenal azotemia is anabnormally high level of nitrogen-type wastes in the bloodstream). Medical hx of CAD, MI x5, DM type 2, PVD, HTN and cholecystectomy (removal of the gallbladder). Allergic to codeine,full code status, IV (L) hand NS 75ml/hr, full liquid diet, BRP w/assist, I&O q shift, LBM 3/4/06, nurse aide reported BP of 63/45 w/dinamap. Primary nurse and I both took a manual BP of118/64. 3/9/09: 1800 ADA diet, saline lock (L) arm, night shift nurse withheld Toprol b/c BP was 107/48, LBM 3/8/06 diarrhea in the evening.History of present illness: J.D. presented to the ER with 1-week malaise, general abdominal pain, nausea and vomiting. ER lab reported leukocytosis. IV zofran was administered, but didnot control the nausea and vomiting. Pt was admitted.

Assessment

System Findings-include assessment, labs and dxtests Pathology explanation Nursing implications-includemedications and teaching

Neuro A&Ox3Sensory function WNLMotor function WNL

No seizure or tremors No assessment changes 2ndday

WNL Continue to assess and monitor q shift and prn for mentalstatus changes or other neuro changes.

Cardiac Hx of CAD, PVD, HTN, MI x5T: 98.2 BP: 118/64 P: 71T: 98.8 BP: 111/46 P: 71Apical pulse: 78, 3/9/06: 84Radial and dorsalis pedal pulses: weak, regular(L) foot: anterior localized edema, 1+ nonpittingBUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia,dehydration, CHF, MI, renal disease

RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietarydeficiency and renal failureHgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,dietary deficiency, kidney diseaseHct 27.4% (normal female 37-47%) indicates anemia, dietarydeficiencyK+ WNL

No other assessment changes 2ndday

Coronary artery disease atherosclerosis is majorcause of CAD, the vessel lumen narrows andrestricts blood flow and inadequate oxygenation ofmyocardial tissues occur this can cause decreasedperipheral pulses.Myocardial infarction myocardial tissue is severelydeprived of O2 and ischemia develops which canlead to necrosis of the tissues.

PVD arterial occlusion deprives the lowerextremities of O2 and nutrients this can causedecreased pedal pulses.

Encourage pt to maintain a minimum fluid intake of1500ml/day (7a-3p 600ml / 3p-11p 600ml / 11p-7a300ml) Consult MD if pt is on diuretics and experiencessignificant weight loss (>2lb/day or 5lb/wk), weigh ptdaily. Place pt in semi- to high Fowlers position todecrease cardiac workload. Instruct pt to avoid straining(b/c of constipation, holding breath while moving up inbed). Encourage deep breathing exercises to supply

adequate O2 to tissues. Administer medications asprescribed.Digoxin 0.125mg PO qd Lotrel 5-10 PO q AMPlavix 75mg PO qd Lotensin 10mg PO q AMLasix 20mg PO q AM Isordil 20mg PO TID

Resp R: 20 R: 18 Pt on room air O2 sat: 97%Lung sounds clearNo cough No SOB

Non-smoker No other assessment changes 2ndday

WNL Continue to assess V/S q shift and lung sounds

GI

Abdomen: soft, nontender to touchBowel sounds x4LBM: 3/4/06

Intermittent abdominal pain: 6 out of 10, sharp, dullIntermittent nausea, no vomiting noted3/8/06: clear liquid diet 3/9/06: 1800 ADAUsual bowel pattern: once q 3 days3/9/06: pt stated she had small amt of diarrhea previousevening.RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietarydeficiency and renal failureHgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,dietary deficiency, kidney diseaseHct 27.4% (normal female 37-47%) indicates anemia, dietarydeficiencyAlbumin 2.8g/dl (normal: 3.5-5g/dl) indicates malnutrition,inflammatory disease

Diverticulitis is inflammation of the diverticula in theintestinal walls. Infection results from food and/orbacteria that become trapped in the diverticulum.

This is caused by not enough fiber in the diet, andconstipation is usually a problem.

Encourage pt to defecate whenever the urge is felt.Encourage pt to establish a regular time for defecation(ex: 1 hour after eating). Encourage an increase in high-

fiber foods. Instruct pt to increase fluid intake to2500cc/day (7a-3p 1100cc, 3p-11p 1100cc, 11p-7a300cc). Encourage hot liquids in the mornings (coffee,tea). Administer laxatives/stool softeners as ordered.Administer pain meds as ordered. Administerantiemetics as ordered.Reglan 10mg PO ACZofran 4mg IV PRN q4-q6 for nausea/vomitingDemerol 25mg IV q4 PRN for painKaon-CL (KCL) 10mEq PO qAMNeurotin 300mg PO TID (unlabeled use: chronic pain)

GU

Prerenal azotemia

Pt voids in bathroomNo I&O orderedNo bladder distention notedNo c/o urgency or hesitation

Azotemia is excess urea and nitrogenous wastes in

the bloodstream due to kidney insufficiency and iscaused by conditions that reduce blood flow to thekidneys. These conditions include prolongedvomiting, diarrhea, heart failure. To correct

Encourage an increase in high-fiber foods. Instruct pt to

increase fluid intake to 2500cc/day (7a-3p 1100cc, 3p-11p 1100cc, 11p-7a 300cc) to prevent hypovolemiawhich results in decreased cardiac output.Place pt in semi- high Fowlers position to reduce cardiac

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RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietarydeficiency and renal failureHgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,dietary deficiency, kidney diseaseBUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia,dehydration, CHF, MI, renal disease/failureCrea: WNLK+ WNL

No assessment changes 2ndday

azotemia, you need to correct the source of theproblem, which is reduced blood flow.

workload, instruct pt to avoid straining. Promote physicaland emotional rest. Encourage deep breathing foradequate tissue oxygenation.Kaon-CL (KCL) 10meq PO qAM

Musc-skel Limb movements x4 WNLNo c/o pain/stiffness

Pt sits, walks, stands and turns independentlyPosture/gait: WNL

No assessment changes 2ndday

WNL Continue to monitor for any problems with walking or painq shift/prn.

Integ Skin warm and drySkin intact(L) foot: anterior localized edema, 1+ nonpitting

No assessment changes 2ndday

Edema due to cardiovascular problems as statedabove.

Continue to assess and monitor edema and skin for anychanges q shift and prn.

Endocrine Glucose:3/7/06: 2233/8/06: 1503/9/06: 119

DM type 2 is due to insulin resistance of the cellsresponse, or the pancreas doesnt produce enoughinsulin and this affects protein, carbohydrate and fatmetabolism.

Assess for s/sx of hyperglycemia q shift and prn.(frequent urination, excess thirst/hunger, dry mouth,fatigue, weight loss). Administer insulin as ordered.Novolog sliding scale SC AC HSNovolin 70/30 SC BID AC 35units

Psycho-

social

Pt has family/friends that visit. She lives alone. She doesnot drink alcohol. She is knowledgeable about her medicalhx conditions, though she seems to lack knowledgeregarding nutrition. She suffers from insomnia sometimes.

Nutrition problems in the elderly can be common,could be due to financial resources or knowledgedeficit on nutrition facts.

Assess reasons for nutrition deficit. If financial, refer pt tosources (ex: Lone Star program), if knowledge deficit, ptneeds teaching on her nutrition. Encourage familyinvolvement.Ambien 10mg PO HS PRN for insomnia

Discharge planning: indicate likely patient needs or ongoing problems on discharge. Nursing actions to provide for those needs.Need: Pt needs teaching regarding how to prevent constipation.Action: Help pt to understand and know that certain medications can have a constipatingside effect. Send home with her a cup with measurement on it just like she used in the hospital.

MD contact if physician needed to be called, state what you would say:

Dr. was not called. Sample phone call: I would have the MAR, labs, chart available before placing this call.

Hi, this is Community City hospital calling about your patient Jane Doe. in room 22A. She has developed increased abdominal pain 10 out of 10 and is doubled over.The location of the pain is in the LLQ with distention. She is doubled over in pain and crying. The Demerol was given 20 mins ago and has not helped. There is nobladder distention. Would you like me to prep her for an MRI, CT scan or ultrasound? Also would you like to increase the Demerol or administer another painmedication? I would write down any orders as he/she speaks, and then read them back to him for confirmation. I would document that I made the phone call and whattime it was made, as well as any new orders he gave.

Prioritize: list your patients in order of priority; least stable to most stable: explain why

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