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RUNNING HEAD: Concept Care 1
Database: S.M. is a 29 year old male triaged as a level 3 for a sore throat. I took care of
S.M. on February 4th, 2015 in the Emergency Department. S.M. is a single, Caucasian male who
speaks fluent English. S.M. is currently employed at the mine. He identifies with the Christian
faith. S.M. has a girlfriend and their 3 year old daughter in the room with him.
Reason for Seeking Hospitalization: Patient claims his throat hurts so bad he can barely
swallow. He claims it hurts mostly on the left upper back jaw and throat.
Medical Hx- Past and Present medical Dx:
Past Dx:
1. Left Shoulder Dislocation: Displacement of the head of the humerus beyond the
boundaries of the glenoid fossa. The most common cause is from trauma with the arm in
external toation with abduction, causing the head of the humerus to sublux anteriorly; a
posterior subluxation may occur from a fall on a n outstretched arm. An inferior
dislocation may occur from poor muscle tone as with hemiplegia and from the weight of
the arm pulling the humerus downward. Anterior glenohumeral dislocations are common
among athletes, especially football players. (Nursing Central Mobile App, Taber’s
Medical Dictionary)
S/S: A patient with a dislocated shoulder usually has a hollow in place of the normal
bulge of the shoulder, as well as a slight depression at the outer end of the clavicle.
Glenohumeral range of motion is restricted and such patients often cannot touch their
opposite shoulder with the hand of the involved arm. Both shoulders should always be
Concept Care Plan 1
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compared for symmetry. Vital Signs are assessed to provide baseline data. The patient is
assessed for pain, and analgesia prescribed and provided as needed. (Nursing Central
Mobile App, Taber’s Medical Dictionary)
Current Dx:
2. Peritonsillar Abscess: An abscess is a localized collection of pus in any body part,
resulting from invasion of a pyogenic bacterium or other pathogen. Staphylococcus
aureus, e.g., methicillin-resistant S. aureus (MRSA) is a common cause. The abscess is
surrounded by a membrane of variable strength created by macrophages, fibrin, and
granulation tissue. Abscesses can disrupt function in adjacent tissues and can be life
threatening in some circumstances, e.g., in the lung or within the peritoneal cavity. So, a
peritonsillar abscess is an abscess of the tissue around the tonsillar capsule. Needle
aspiration of the abscess, with subsequent antibiotic therapy, is an effective treatment in
90% of cases. (Nursing Central Mobile App, Taber’s Medical Dictionary)
S/S: The mouth and throat may show a swollen area of inflammation - typically on one side.
The uvula may be shoved away from the swollen side of the mouth, lymph glands in the neck
may be enlarged and tender, severe sore throat that becomes isolated to one side, painful
swallowing, fever and chills, muscle spasm in the muscles of the jaw and neck, ear pain on the
same side as the abscess, a muffled voice, often described as a "hot potato" voice (sounds as if
you have a mouthful of hot potato when you talk), and difficulty swallowing saliva. (Lubin,
J.S., 2014, para.2)
My patient exhibited signs of enlarged, tender lymph nodes bilaterally in the neck. He stated
he had a very sore throat and that it was even difficult for him to swallow his own spit. His
Concept Care Plan 1
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left tonsil and back, upper jaw are inflamed and reddened. There are significant white patches
of pus primarily on the left tonsil and back, upper jaw. Patient had a slightly elevated
s
Situation
temperature at 1348 taken temporally at 99.2 degrees Fahrenheit.
Background
B
Assess what is
happening in a
short statement
Summarize
important past
assessment data for
your patient here.
Place lab results and
medication on the
concept map
Patient presents as:
S.M. is a 29 year old Caucasian, single male in the ED with a severe sore
throat. Patient states he has difficulty swallowing his own saliva and is in
pain. He states the pain is located more on his left back, upper jaw and left
tonsil. He claims he has had the sore throat for five days prior to coming in
for assessment and treatment. He was triaged as a level 3 and was soon
swabbed to R/O strep throat.
Age:
29
Gender:
Male
Allergies: Meperidine HCL (From Demerol)
Fall Risk: NO, Pt. walks into ED
independently with a steady gait.
Isolation: Universal precautions
A
Concept Care Plan 1
4
Use the
assessment data
to complete your
concept map
Vital Signs:
11:12: Temp: 97.5, Pulse: 102, Respirations: 16, BP: 126/79, O2: 100.
12:27: Temp: 97.8, Pulse: 88, Respirations: 20, BP: 93/61, O2: 91
(Had to reassess after O2 dropped to 86 suddenly, O2 put on via nasal
cannula at 1.5 Liters). After intervention:
12:30: Temp: 97.6, Pulse: 86, Respirations: 18, BP: 93/61, O2: 96
13:20: Temp: 98.0, Pulse: 95, Respirations: 18, BP: 106/59, O2: 94
13:48: Temp: 98.0, Pulse: 95, Respirations: 18, BP: 106/59, O2: 92
13:53: Temp: 99.2, Pulse: 97, Respirations: 18, BP: 104/67, O2: 94
General:. Patient is alert and oriented to person, place, and time. He is
sitting back in High Fowlers in bed talking to his daughter and girlfriend.
Patient claims he is in pain rated at an 8 on a verbal scale from 0-10. He
only asks for pain control at this time and has no other unmet needs. He
has blue eyes and brown hair. He has adequate hygiene. The patient is a
6’3 tall male weighing 119.7 kg. He has adequate muscle tone, no atrophy
or dystrophy noted. S.M. is capable of ambulating with no problem
independently with a steady gait bilaterally. S.M. has adequate hearing as
evidenced by the ability to respond to questions being asked in an average
volume of my voice. He can communicate effectively, but softly due to his
throat pain. His skin color is pink and dry and warm with slightly pale lips.
Assessment
HEENT: Patient has normocephalic skull that is symmetrical. There were no
lumps, bumps, or lesions found on scalp. There were no nits or lice found either.
The patient had a symmetrical face overall. He has facial hair full with a beard
and mustache. His eyes were almond shaped and were blue with no visible
discharge. Ears were symmetrical bilaterally. There was no presence of lesions on
either ear. The patient’s tympanic membranes were pearly grey equal bilaterally.
There was no visible ear wax buildup. The patient’s nose was symmetrical with
no septum deviation. His nares were moist and pink with little black hair. There
was no discharge or lesions in her nares. His lips were pale and dry and
symmetrical. His mucous membranes in his oral cavity were slightly pale, pink
and moist. His throat was inflamed and reddened with substantial white pus
patches on his left tonsil and back, upper jaw. His teeth were white and straight
and there were no carries. The patient’s neck was supple. Lymph nodes are
palpable equally bilaterally in neck and also in the left supraclavicular region.
Integumentary: Patient’s skin is warm, dry, and pink. He has multiple tattoos
covering most of his upper arms bilaterally and partially on his right forearm. His
overall skin condition was excellent with no skin breakdown visible. He had a
couple of small yellow/green contusions on left shin about 10 mm in diameter.
Patient had a left antecubital IV in place that was intact, no redness, swelling, or
drainage seen at the site throughout the shift. His nares show no evidence of
irritation or redness. The patient’s fingernails were very clean and trimmed. They
were white and pink at the nail beds. His toenails were also very clean and
trimmed and were white and pink at the nail beds. Braden Scale Score: Sensory
Perception: 4=No impairment. Moisture:4=Rarely Moist. Activity:3=Walks
Occasionally. Mobility:3=Slightly Limited. Nutrition:4=Excellent. Friction and
Shear:2=Potential Problem. TOTAL SCORE=20.
Concept Care Plan 1
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Respiratory: The patient’s fingernails and toenails were pink. His lips
looked slightly pale. His mucous membranes were also pale, pink and
moist. His respirations per minute were within normal limits from 16-20
breaths per minute. His chest rose and fell equally bilaterally and his
respirations are unlabored. He had no nasal flaring or grunting. His anterior
posterior chest diameter was normal at a 1:2 ratio. He had clear, vesicular
breath sounds in all lobes in each lung. After morphine and Zofran were
administered, about 10 minutes later, the patient’s oxygen saturation
dropped from 91% to 86% all of a sudden. Pt. exhibited no other signs of
cyanosis except pale lips on the verge of a blue tinged. O2 via nasal
cannula was put on 1.5 Liters and the patient’s O2 went back up to 96%.
His oxygen saturation showed no other major fluctuation except for this
instance and was taken off of the nasal cannula after his oxygen saturation
reached 96 and he maintained a stable O2 sat. Pt. was negative for
bronchophony and egophony. Patient had no crackles, rhonchi, or
wheezing. No history of respiratory disease or illness. Pt has no cough. Pt.
has difficulty clearing secretions in mouth due to sore throat and difficulty
swallowing due to pain. Pt. spits in cup and sputum is clear with no odor.
Cardiovascular: Upon auscultation the client’s heart, I heard regular rate
and rhythm and so the client had normal S1 and S2 sounds. There were no
murmurs heard. The apical pulse was equal to the patient’s radial pulse.
The right and left radial pulses were equally bilaterally, both rated at a 2+.
The pedal pulses were equally bilaterally, both rated at a 2+. His carotid
pulses were rated at a 2+ equally bilaterally. The capillary refill of the
patient’s lower extremities was immediate and the capillary refill of the
patient’s upper extremities was also immediate. There was no clubbing of
his nails noted. Homan’s sign is negative bilaterally. Patient has no
evidence of any pitting and non-pitting edema on either lower extremity,
sacrum, or on upper extremities.
GI: The patient’s abdomen is round and soft and there is no distention.
There were no scars or lesions noted on the patients abdomen. He denies
any pain or tenderness upon palpation. Patient states he has some nausea
rated at a 5 on a verbal pain scale of 0-10. He states he has no vomiting or
diarrhea. Upon auscultation, the patient has normoactive bowel sounds
heard within 3 seconds in each of the four quadrants. Patient states he was
unable to eat today due to the pain caused from the abscess. Pt. denies any
problems with bowel movements and denies any abnormal appearance of
stools.
GU: The patient did not void while I took care of him, but he denied any
problems with voiding. He denied any burning or pain upon urination. He
claims his urine hasn’t looked cloudy, bloody, and has not noticed any
particles either. No history of any UTI’s or kidney stones.
Concept Care Plan 1
6
NEURO: Patient is alert and oriented times three. His pupils were round
and reactive bilaterally. They were about 3mm in diameter and constricted
and dilated bilaterally when light was shined at them. His eyes
accommodated equally bilaterally. He was able to follow penlight with
both eyes equal bilaterally in all 6 cardinal directions without any head
movement. His hand grips were rated at a 5 equal bilaterally and his foot
pushes were rated at a 5 equal bilaterally. The patient was able to swallow,
but with trouble due to his pain, but his uvula rose and fell equally. The
patient had adequate hearing equal bilaterally. There were no abnormal
speech patterns upon communicating with the patient. Patient had a
symmetrical smile and was able to stick his tongue out and move it side to
side equally bilaterally. Patient was able to shrug shoulders against
resistance and move head against resistance. All cranial nerves are intact.
PAIN: Patient rates pain as an 8 on a verbal pain scale from 0-10. It is
located on the left side of his throat and back, left, upper jaw.
Cultural: Pt. is 29 year old Caucasian male whose primary language is
English. He identifies with the Christian faith. I was able to communicate
well and effectively with the patient and he felt comfortable expressing his
concerns with me. I started his left, antecubital peripheral IV and he stated
that he was scared of needles and hated getting IVs. He showed a lot of
anxiety and fear so I talked him through the process and he seemed to calm
down a little bit.
Concept Care Plan 1
Evaluate your
nursing care and
make
recommendations
Related to the
achievement of
your desired
outcomes. Were
they met, or do new
goals need to be
established?
Diagnosis 1
7
Goal: Patient will demonstrate
effective coughing and clear breath
sounds q 2 hours and will maintain
a patent airway throughout my
clinical shift.
Outcome met?
Yes
I auscultated the lung sounds on this patient q 2 hours and told him to
deep breathe and cough and patient did this effectively and lung sounds
were clear in all lobes. I gave the patient a cup since he had difficulty
swallowing his own saliva due to the pain and inflammation he was
experiencing in his throat. He was able to spit out the saliva so he did not
risk aspiration. His airway remained patent and the inflammation was
controlled by the anti-inflammatory steroid I administered via IVP over
two minutes.
Diagnosis 2
Goal: Pt will use the verbal selfreport pain tool on a numerical
scale of 0-10 q hour with vitals and
report that pain management
regimen achieves comfort-function
goal without side effects throughout
my clinical shift.
Outcome met?
Yes
Initially, I administered 2 mg of Morphine via IVP. The patient stated that
he did not feel much relief after the administration of Morphine. Then,
Phenol Chloraseptic Throat Spray was self-administered, 2 puffs PRN and
patient stated that it “worked better than the morphine” and lowered his
pain level from an 8 to a 4.
Diagnosis 3
Goal: Client will identify and
Outcome met?
verbalize symptoms of anxiety
whenever they feel it and will
YES
identify, verbalize, and demonstrate
techniques to control anxiety
throughout my shift.
Concept Care Plan 1
Evaluate your
nursing care and
make
recommendations
Related to the
achievement of
your desired
outcomes. Were
they met, or do new
goals need to be
established?
8
The patient displayed signs of
anxiety with increased rate and
shallow respirations and tachycardia
and feeling of faintness because I
told him I would have to start an IV
on him. He told me he was deathly
afraid of needles and that he was
scared. He said that he was
“freaking out”. I talked him through
the procedure and told him to look
away while I put the needle in and it
calmed him down a little bit as
evidenced by lowered respiratory
rate and lowered heart rate.
Diagnosis 4
My client will be educated about
the signs and symptoms of bleeding
postoperatively and will maintain
warm, dry skin throughout my
clinical shift.
Outcome Met?
NO
I was unable to monitor my patient for bleeding because he was
admitted to the floor for observation over-night. He was scheduled to get
surgery for his abscess the next day.
Name/ Classification
Indication
Adverse Reaction
Morphine/Opioid Analgesics
Pain rated at an
8, intolerable to
patient. Pain
location on left
side of throat
and upper left
jaw.
Respiratory
depression,
constipation,
hypotension,
sedation, dizziness.
Phenol Spray/ Chloraseptic Throat
Spray/ Analgesic/Oral Anesthetic
Pain in throat on
left side rated at
an 8 after
morphine did
not touch the
pain.
Headache, nausea,
vomiting
Ondansetron/ Anti-emetic
Nausea rated at
a 5 on a 0-10
verbal scale.
Headaches,
dizziness,
constipation,
diarrhea, dry
mouth
CNS depression,
euphoria,
hypertension,
anorexia, nausea,
fragility, adrenal
suppression
Allergic reactions,
Concept Care Plan 1
Methylpredinsolone/Corticosteroids Throat
inflammation.
Cefazolin/ Anti-infectives
Prophylaxis for
Medications
administered and
nurse evaluation
9
of Patient
response
2mg IVP Now.
Pt. states his pain
is still at an 8. He
states he doesn’t
feel like the
morphine helped
much. Pt.’s O2
saturation
dropped to 86%
after
administration,
pt. was put on
O2 via nasal
cannula at 1.5
Liters. Pt.’s O2
saturation went
back up to 96
within 1 minute
and the O2 nasal
cannula was
discontinued.
2 puffs PRN.
Pt. states the
chloraseptic
spray
immediately
relieved his pain
in his throat and
that it “works
better than the
morphine you
gave me.” He
rated his pain at a
4 after using the
spray.
Pt. denies any
complaint of
nausea after
Zofran is
administered.
Pt. tolerated well
with no adverse
reactions.
Inflammation in
throat was still
visible.
Pt. tolerated well
Concept Care Plan 1
Clindamycin/Anti-infectives
10
potential surgery
and also to treat
the already
existing abscess
in throat.
Prophylaxis for
potential surgery
and also to treat
the already
existing abscess
in pt.’s throat.
diarrhea, nausea,
vomiting, rash,
pruritis.
with no adverse
reactions.
Diarrhea, nausea,
bitter taste,
headache,
hypotension.
Pt. tolerated well
with no adverse
reactions.
XRAYS:
CT Neck with Contrast
Findings: Asymmetric soft tissue
swelling in the left oral tonsil,
central low density with this
tissue and I suspect this could
represent a very early tonsillar
abscess, though there may not yet
be complete liquidation. Low
density area measures 1x1.7cm
in max size. Asymmetric
effacement of the lower oral and
upper hypopharynx. Epiglottis is
thin, some lymph nodes in the
neck and left supraclavicular
region, which are presumably
reactive.
Impression: Asymmetric soft
tissue swelling of the left oral
tonsil. I suspect there is a
small/evolving, left tonsillar
abscess measuring 1x1.7 cm in
maximum dimension. ENT
consultation might be of
additional benefit.
Concept Care Plan 1
11
Lab (consider diagnosis)
NEUT%
LYMPH%
Value (high or low)
79.2 HIGH
11.4 LOW
WBC
EOS%
BASO%
NEUT#
MONO#
EOS#
Total Bilirubin
14.17 HIGH
0.0 LOW
0.1 LOW
11.21 HIGH
1.28 HIGH
0.00 LOW
2.07 HIGH
Group A Strep Screen
NEGATIVE
Clinical indication
Infection
Septicemia, malnutrition,
pneumonia
Inflammatory infection
Infections
Acute infection
Infections
Infections
Infections
Infectious mononucleosis,
hepatitis, hypothyroidism
Negative for Strep Throat
Psychosocial:
I experienced a moment with this patient that I found to be interesting and further proves that
each patient is an individual and has unique and diverse needs and reactions to interventions. I
had to start an IV in this patient and when I entered the room with the IV start kit, I noticed his
eyes got wide and he anxiously asked me, “What’s all that stuff for?”. I explained to him that the
doctor ordered an IV and that I was going to be the one to do it. He gave me permission to do so,
but with a lot of fear. He admitted that he was really scared of needles and his respirations started
to increase in rate and became shallow. He closed his eyes and looked away from his left arm
which is where I chose to start the IV. He said he started to feel a little dizzy, due to his anxiety. I
calmly and slowly talked him through the process as I started his IV and drew blood. This
seemed to gradually help reduce his anxiety and once the blood draw was over, he claimed his
anxiety was relieved. What I found to be interesting deals with stereotyping. This patient was a
very tall, well-built young male with facial hair and tattoos all over his arms. Initially I viewed
him as a “tough-guy”, and yet he was not afraid to reveal his fear of needles, which to some
could be emasculating.
Concept Care Plan 1
Nursing Diagnosis 1
Ineffective Airway
Clearance r/t pain in
throat AMB difficulty
swallowing and spitting
into cup.
1)Auscultate breath
sounds q2 hours. (Ackley
&Ladwig, 2012, Pg.130)
2) Monitor respiratory
patterns, including rate,
depth, and effort.
(Ackley &Ladwig, 2012,
Pg.130) 3) Administer
Oxygen as ordered.
(Ackley &Ladwig, 2012,
Pg.130) 4) Position the
client to optimize
respiration HOB at 30-45
degrees. (Ackley
&Ladwig, 2012, Pg.130)
Nursing Diagnosis 4
Risk for bleeding r/t surgical
intervention for abscess.
1)Watch for signs of
bleeding including: bleeding
of the gums, blood in
sputum, emesis, urine, or
stool q 1 hour. (Ackley
&Ladwig, 2012, Pg.157)
2)Assess vital signs q 1 hour
looking for tachycardia,
tachypnea, and hypotension.
(Ackley &Ladwig, 2012,
Pg.158) 3) Monitor all
medications for the potential
to increase bleeding such as
aspirin and NSAIDS
throughout my shift.
(Ackley &Ladwig, 2012,
Pg.158) 4) Perform
admission risk assessment
for falls and for signs of
bleeding. (Ackley&Ladwig,
2012, pg. 157)
Nursing Diagnosis 2
Acute Pain r/t left tonsil abscess
AEB rating pain at an 8 and
intolerable verbally on a scale from
0-10.
1)I will determine if the client is
experiencing pain at the time of the
initial interview. If pain is present,
conduct and document a
comprehensive pain assessment
and implement or request orders to
implement pain management
interventions to achieve a
satisfactory level of comfort.
(Ackley &Ladwig, 2012, Pg. 577)
2)I will assess pain intensity level
in a client using the verbal 0-10
numerical pain rating scale.
(Ackley &Ladwig, 2012, Pg. 577)
3)I will assess the client for pain
presence routinely with vital signs
and after pain med admin. (Ackley
&Ladwig, 2012, Pg. 577) 4)I will
ask the client to describe prior
experiences with pain,
effectiveness of pain management
interventions, responses to
analgesic medications and their
side effects on the pt. (Ackley
&Ladwig, 2012, Pg. 577)
Condition:
Peritonsillar Abscess, Left
Tonsil and left,back, upper
jaw.
12
Nursing Diagnosis 3
Anxiety r/t fear of needles
AMB patient stating, “I’m
deathly afraid of needles.”
1)Use empathy to encourage the
client to interpret the anxiety
symptoms as normal throughout
my shift during feared
procedures. (Ackley &Ladwig,
2012, Pg.138) 2) If irrational
thought or frears are present,
offer the client accurate
information and encourage him
to talk about the events
contributing to the anxiety
throughout my shift. (Ackley
&Ladwig, 2012, Pg.138) 3)
Explain all activities,
procedures, and issues that
involve the client throughout
my shift. (Ackley &Ladwig,
N
2012, Pg.138) 4) Intervene
u
when possible to remove
r
sources of anxiety throughout
s my shift. (Ackley &Ladwig,
i 2012, Pg.138)
n
g
Age: 29
D
i
a
g
n
o
s
i
s
5
Concept Care Plan 1
13
References
Ackley , B.J., Ladwig, G.B. (2014). Nursing Diagnosis Handbook An Evidence-Based Guide to Planning
Care.
Taber's Medical Dictionary, Nursing Central Mobile APP.