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 an
abnormally 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 of
118/64. 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 did
not control the nausea and vomiting. Pt was admitted.

Assessment
System Findings-include assessment, labs and dx Pathology explanation Nursing implications-include
tests medications and teaching
Neuro A&Ox3 WNL Continue to assess and monitor q shift and prn for mental
Sensory function – WNL status changes or other neuro changes.
Motor function – WNL
No seizure or tremors No assessment changes 2nd day
Cardiac Hx of CAD, PVD, HTN, MI x5 Coronary artery disease – atherosclerosis is major Encourage pt to maintain a minimum fluid intake of
T: 98.2 BP: 118/64 P: 71 cause of CAD, the vessel lumen narrows and 1500ml/day (7a-3p 600ml / 3p-11p 600ml / 11p-7a
T: 98.8 BP: 111/46 P: 71 restricts blood flow and inadequate oxygenation of 300ml) Consult MD if pt is on diuretics and experiences
Apical pulse: 78, 3/9/06: 84 myocardial tissues occur – this can cause decreased significant weight loss (>2lb/day or 5lb/wk), weigh pt
Radial and dorsalis pedal pulses: weak, regular peripheral pulses. daily. Place pt in semi- to high Fowlers position to
(L) foot: anterior localized edema, 1+ nonpitting Myocardial infarction – myocardial tissue is severely decrease cardiac workload. Instruct pt to avoid straining
BUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia, deprived of O2 and ischemia develops which can (b/c of constipation, holding breath while moving up in
dehydration, CHF, MI, renal disease lead to necrosis of the tissues. bed). Encourage deep breathing exercises to supply
RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietary PVD – arterial occlusion deprives the lower adequate O2 to tissues. Administer medications as
deficiency and renal failure extremities of O2 and nutrients – this can cause prescribed.
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia, decreased pedal pulses. Digoxin 0.125mg PO qd Lotrel 5-10 PO q AM
dietary deficiency, kidney disease Plavix 75mg PO qd Lotensin 10mg PO q AM
Hct 27.4% (normal female 37-47%) indicates anemia, dietary Lasix 20mg PO q AM Isordil 20mg PO TID
deficiency
K+ WNL
No other assessment changes 2nd day
Resp R: 20 R: 18 Pt on room air O2 sat: 97% WNL Continue to assess V/S q shift and lung sounds
Lung sounds clear
No cough No SOB
Non-smoker No other assessment changes 2nd day
GI Abdomen: soft, nontender to touch Diverticulitis is inflammation of the diverticula in the Encourage pt to defecate whenever the urge is felt.
Bowel sounds x4 intestinal walls. Infection results from food and/or Encourage pt to establish a regular time for defecation
LBM: 3/4/06 bacteria that become trapped in the diverticulum. (ex: 1 hour after eating). Encourage an increase in high-
Intermittent abdominal pain: “6 out of 10”, sharp, dull This is caused by not enough fiber in the diet, and fiber foods. Instruct pt to increase fluid intake to
Intermittent nausea, no vomiting noted constipation is usually a problem. 2500cc/day (7a-3p 1100cc, 3p-11p 1100cc, 11p-7a
3/8/06: clear liquid diet 3/9/06: 1800 ADA 300cc). Encourage hot liquids in the mornings (coffee,
Usual bowel pattern: once q 3 days tea). Administer laxatives/stool softeners as ordered.
3/9/06: pt stated she had small amt of diarrhea previous Administer pain meds as ordered. Administer
evening. antiemetics as ordered.
RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietary Reglan 10mg PO AC
deficiency and renal failure Zofran 4mg IV PRN q4-q6 for nausea/vomiting
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia, Demerol 25mg IV q4 PRN for pain
dietary deficiency, kidney disease Kaon-CL (KCL) 10mEq PO qAM
Hct 27.4% (normal female 37-47%) indicates anemia, dietary Neurotin 300mg PO TID (unlabeled use: chronic pain)
deficiency
Albumin 2.8g/dl (normal: 3.5-5g/dl) indicates malnutrition,
inflammatory disease
GU Prerenal azotemia Azotemia is excess urea and nitrogenous wastes in Encourage an increase in high-fiber foods. Instruct pt to
Pt voids in bathroom the bloodstream due to kidney insufficiency and is increase fluid intake to 2500cc/day (7a-3p 1100cc, 3p-
No I&O ordered caused by conditions that reduce blood flow to the 11p 1100cc, 11p-7a 300cc) – to prevent hypovolemia
No bladder distention noted kidneys. These conditions include prolonged which results in decreased cardiac output.
No c/o urgency or hesitation vomiting, diarrhea, heart failure. To correct Place pt in semi- high Fowlers position to reduce cardiac
 RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietary azotemia, you need to correct the source of the workload, instruct pt to avoid straining. Promote physical
deficiency and renal failure problem, which is reduced blood flow. and emotional rest. Encourage deep breathing for
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia, adequate tissue oxygenation.
dietary deficiency, kidney disease Kaon-CL (KCL) 10meq PO qAM
BUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia,
dehydration, CHF, MI, renal disease/failure
Crea: WNL
K+ WNL
No assessment changes 2nd day
Musc-skel Limb movements x4 WNL WNL Continue to monitor for any problems with walking or pain
No c/o pain/stiffness q shift/prn.
Pt sits, walks, stands and turns independently
Posture/gait: WNL
No assessment changes 2nd day
Integ Skin warm and dry Edema due to cardiovascular problems as stated Continue to assess and monitor edema and skin for any
Skin intact above. changes q shift and prn.
(L) foot: anterior localized edema, 1+ nonpitting
No assessment changes 2nd day
Endocrine Glucose: DM type 2 is due to insulin resistance of the cells Assess for s/sx of hyperglycemia q shift and prn.
3/7/06: 223 response, or the pancreas doesn’t produce enough (frequent urination, excess thirst/hunger, dry mouth,
3/8/06: 150 insulin and this affects protein, carbohydrate and fat fatigue, weight loss). Administer insulin as ordered.
3/9/06: 119 metabolism. Novolog sliding scale SC AC HS
Novolin 70/30 SC BID AC 35units
Psycho- Pt has family/friends that visit. She lives alone. She does Nutrition problems in the elderly can be common, Assess reasons for nutrition deficit. If financial, refer pt to
not drink alcohol. She is knowledgeable about her medical could be due to financial resources or knowledge sources (ex: Lone Star program), if knowledge deficit, pt
social hx conditions, though she seems to lack knowledge deficit on nutrition facts. needs teaching on her nutrition. Encourage family
regarding nutrition. She suffers from insomnia sometimes. involvement.
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 constipating
side 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 no
bladder 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 pain
medication? 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 what
time 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
 1. J.J. 62yr old Caucasian female admitted 3/8/06, dx new onset seizure and UTI. Pt is A&Ox2, stays confused and cannot recall why she is in
Hospital. Husband w/Parkinson’s at bedside, and she believes he was the one admitted. She called a friend to come get her and take her home.
Friend arrived and was able to give some history on both of them. Pt is alcoholic, but denied alcohol use on admission. Other circumstances
Alerted nurse to call adult protective services.
2. S.M. is a 64yr old Caucasian female admitted 3/8/06, dx of pneumonia w/hx of a stroke. Bilateral lung sounds rales/ronchi. V/S WNL. Bilateral upper
Extremities experienced ongoing uncontrolled movements.
3. C.G. 67yr old Caucasian female admitted 3/6/06, dx vomiting, Hyponatremia and prerenal azotemia. Hx of CAD, MI x5, PVD, DM type 2, HTN, cholecystectomy. V/S WNL
4. J.S. 55yr old Hispanic male admitted 3/5/06, dx acute cholecystitis, cholecystectomy on 3/6/06, V/S WNL, pt ambulates independently, d/c home 3/8/06.
5. R.H. 19yr old Caucasian male admitted 3/5/06, dx of (R) ankle infection, V/S WNL, pt ambulates independently, no wound, skin intact, d/c home 3/8/06.

Teaching:

GI – teaching regarding nutrition to prevent constipation

- Encourage pt to drink something warm in the mornings (cup of coffee) and something warm in the evenings (cup of tea). This will promote bowel activity.
- Encourage pt to eat small frequent meals/snacks.
- Encourage pt to eat supplement bars high in fiber for snacks.
- Encourage pt to increase and to measure her liquids. Advise a minimum of 2000cc – 2500cc/day. (ex: 7a-3p drink 150cc/hr to intake 1200cc/8hr). Provide pt
with small cup with measurement lines.
- Instruct pt how to include more fiber in her diet (ex: avocado, blackberries, baked beans, raisin bran) and increase her fluid intake (ex: 2500cc/day)

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