Download concept map - Allison Morrison

Patient: Lee Y Student Nurse: Allison Morrison
1 Problem/ND: Pain/Acute
1 A.E.B.
 Patient reports pain 10/10 in scrotal area
- Scrotum Edematous, Red
- Pt ambulates slowly due to difficulty
walking (scrotal edema)
 Ultrasound results: – Hydrocele and
inflamed epididymis.
 Physical exam: Grossly swollen scrotum,
warm, reddened, painful to touch.
 Medication: Dilaudid 1mgm ever 3 hrs
prn (pt. requests med q 3 hours)
Rocephin 1 gram every 24 hours
5 Problem/ND Activity Intolerance
A.E.B.
 Patient finds it difficult to ambulate due to scrotal
edema, pressure and pain. Pt. is reluctant to ambulate
to toilet, requests urinal.
 Due to patient request of pain medication every 3
hours, pt. sleeps most of the day.
 Due to obesity, (270 lbs, 5’7”)pt is SOB on
ambulation, hx of sleep apnea.
 CT Scan – Thyroid results unavailable at time of care
 Medication: Levothyroxine/Synthroid 1000mcg/day
Ambien for sleep
Reason for Seeking Care
8 Problem/ND Body Image/Disturbed
A.E.B.
 Scrotum edematous, red x 3 weeks
 Ultrasound – enlarged R scrotum,
Hydrocele inflammed epididymus
 Obesity Weight 270 pounds Height 5’7”
3 Problem/ND Knowledge Deficit
R.T. cognitive impairment
A.E.B.
 Decision making ability:
 Hx of admitted substance abuse
 scrotal
hydrocele – history of unresolved
/ND
Maintenance/Ineffective
chronic inflammation for the past 6 months
 Hx sleep apnea. Pt. refuses to use recommended
CPAP
 Observed leaving the patient care unit without
permission to visit another patient. Ignores
Hospital rules.
 HX HTN, Non compliant with diet, salt intake
 BP 164/107, hypercholesterolemia 273
 Management of hypothyroidism: Non compliant
with meds (Synthroid)

Management of stress
Main Complaint: Severe groin pain (10/10)
Med Hx: Hypothyroid, Hypertension
Obesity, Epididymitis for 3 weeks,
Chronic Back pain, Hx Substance
Abuse.
Surg Hx Laminectomy x 2
Hernia Repair
Arthroscopic Right Knee surgery
Vasectomy
2 Problem/ND Ineffective Airway Clearance
R.T. Tracheobronchial obstruction
A.E.B.
 CT Scan: Suspect polyps, upper airway
obstruction in area of glottis and tongue
when sleeping.
 Respiratory Studies: SPO2 89% Room Air
 Loud snoring , then sudden apnea, patient
awakes
 Auscultation – lungs clear, breath sounds
20% diminished bilaterally
 Medication: Albuterol 2.5 mg BID
Atrovent .02% BID
Ventolin
4 Problem/ND Anxiety
A.E.B.
 Unable to sleep for more than 1 hour
 Pt. stated he delayed treatment because he
has to care for his 2 teenagers
 Patient voices concern over unemployment,
lack of access to food stamps
 Elevated blood pressure 164/107
 Fatigue sleeps during the day
 Appears depressed over unemployment
status and loss of future food stamps.
 Patient reports recent episodes of severe
anger due to living situation and pain
 Patient admits: “uses cocaine/alcohol to
numb anxiety”
7 Problem/ND Coping, Ineffective
A.E.B.
 Expressed inability to cope with current
life stressors
 Hx cocaine abuse (last year)
 Alcohol abuse (within last month)
 Patient and mother admit the patient has
rages of anger due to current life situation
 Fatigue (sleep apnea)
 Mentally impaired – unable to grasp
importance of treatments for sleep apnea,
or medication regime of Hypothyoidism
 Claustrophobic patient admits this prevents
him from wearing nasal cannula
6 Problem/ND Health Maintenance/Ineffective
R.T. perceptual cognitive impairment
A.E.B.
 Current health status – impaired
breathing SPO2 89% Room air
 Personal habits – smoking, alcohol
 Psychosocial status – drug use
 Neurological status – poor judgement
– choices in diet and smoking despite
obesity and poor respiratory status
PATIENT PROFILE DATABASE
Student Name: Allison Morrison
ADMISSION INFORMATION
11-10-06
1. Date of Care:
2. Patient
11/15/06
Initials
Lee Y
3. Age
37
4. Growth and Development
Generatively/Stagnation
5. Sex:
M
6. Admission Date:
11-10-06
7. Reason for Hospitalization (face sheet):
8. Medical Diagnoses: (present diagnoses, past diagnoses; physician’s history
Acute Scrotal Pain 10/10 past 2-3 weeks
epididymitis recurrent/ failed out patient treatment,
hypothyroidism / obesity / sleep apnea/ hypertension
and Physical notes in chart; nursing intake assessment and Kardex)
9.
Surgical Procedures (consent forms, chart):
Consent form: Not applicable
Prior surgery: Laminectomy x 2, Vasectomy, Right
knee arthroscopy
10.
ADVANCE DIRECTIVES (Nurse’s Admission Assessment)
Living will: _____yes ___X___no
11.
Power of attorney: ______yes ___X___no
Do not resuscitate (DNR) order:
______yes __X____no
LABORATORY DATA
Test
Norms
.47-4.53
On Admission
Current Value
Test
On Admission
161
Thyroxine TSH
Potassium
Differential
Triglycerides
14-18
Norms
13.1
Hemoglobin
30-149
193
140-199
213
Cholesterol
42-52
37.9
36.8
Low-density
lipoproteins
60-99
125
4.1-5.5
3.84
3.73
Urine Protein
0
15
SGOT
0-45
199
International
Normalized ratio
SGPT
0-45
105
Activated partial
Thromboplastin time
BUN
8-20
22
Hematocrit
RBC
Prothrombin Time
Current
Value
12.
DIAGNOSTIC TESTS
Chest x-ray: WNL
EKG: WNL
Ultrasound – scrotum
No testicular torsion, no masses
Rgt testicular enlarged, mod hydrocele
Pulmonary function tests – WNL during the
day, reduced function at night (SpO2 = 89%)
Some reduction (20%) in breath sounds
Ultrasound – thyroid 11/14 no results
CT scan 11/13 still no results
13.
MEDICATIONS
List medications and times of administration (medication administration record and check the drawer in the carts)
Medication/Time of Administration
Actions
Side effects
Albuterol 2.5 mg/3 ml BID
bronchodilator
Tremor, nervousness insomnia,
headache, weakness, malaise
Heparin 5000 U/ml SC Q12
Anticoagulant prevention of embolism
Fever overly prolonged clotting time,
thrombocytopenia
Ibuprofen 6000 mg PO Q6
Analgesic mild to moderate pain relief
Headache dizziness nervousness
Atrovent .02% BID
Prevent bronchospasm associated with chronic
bronchitis and emphysema
Dizziness pain headache nervousness
Levothyroxine 1000 mcg daily PO
Thyroid hormone replacement
Nervousness insomnia tremor
headache
Ambien 10 mg HS PO
Sleep promotion prevent insomnia
Drowsiness dizziness headache
Sodium Chloride .9% LVP IV 100ml/hour
Maintain fluid volume and electrolyte
replacement
Edema or aggravation of heart failure
Ventolin 2 puffs PRN
bronchodilator
Tremor nervousness dizziness
insomnia weakness malaise
Rocephin 1 gm in 50 ml .5% dextrose TID IVPB give
over 30 min
Antibacterial antibiotic - gynecologic infections
septicemia
Headache fever dizziness
Dilaudid 1 mg IV push Q 4 give over 2-3 minutes
(hydromorphine hydrochloride)
Pain reduction
Sedation somnolence dizziness
euphoria
ALLERGIES/PAIN
14.
Allergies (medication administration records):
Penicillin – patient not wearing ident band
15. Where is the pain? 10 /10 scrotum best is 5 most recent
best is 8 (nurse’s notes)
TREATMENTS
14. When was the last pain medication given? (medication administrative record):
every 4 hours
15. How much pain is the patient in on a scale from 0-10? 10
16. Treatments: medication management, must wear athletic supporter
24 hours (patient did not have one, Student Nurse alerted Nurse
about this so it was secured
smoking cessation consultation,
19.
17. Support services:
Respiratory therapy considering cpap
18. Consultation:
Infectious disease,
surgery, pulmonary,
urology
DIET/FLUIDS
Type of Diet: normal
Restrictions: none
Gag reflex intact:
__X__yes ____no
Appetite:
Breakfast
Large appetite –2 breakfasts
eaten 100___%
Lunch
______%
Supper
_____%
Circle Those Problems That Apply:






Fluid Intake:
24 hours
(flow sheet)
Tube feedings:
Type and rate
(flow sheet)
20.
Problems: swallowing, chewing, dentures (nurse’s note)
Needs assistance with feeding (nurse’s notes)
Nausea or vomiting (nurse’s notes)
Overhydrated or dehydrated (evaluate total intake and output on flow sheet)
Belching
Other
INTRAVENOUS FLUIDS (IV Therapy Record)
Type and rate:
IV dressing dry, no edema, redness of site:
___X_yes _______no
Other:
.9% saline 100ml/hour
21.
ELIMINATION (flow sheet)
Last bowel movement: daily (as per
patient)
24-hour urine output: WNL
Foley/condom catheter:
______yes ___X___no
Circle Those Problems That Apply:



22.
Bowel:
Urinary:
Other:
constipation
hesitancy
diarrhea
frequency
flatus
burning
incontinence
incontinence
bel ching
odor
ACTIVITY (flow sheet)
Ability to walk (gait):
WNL as of 11/14
Type of activity orders:
No restrictions
No. of side rails
Required (flow sheet): 0
Restraints (flow sheet):
______yes _X_____no
Use of assistive devices:
cane, walker, crutches, prosthesis
Weakness:
______yes ___X___no
Falls-risk assessment rating:
(flow sheet) not at risk
Trouble sleeping (nurse’s notes):
___X___yes ______no
severe sleep apnea, loud snoring
PHYSICAL ASSESSMENT DATA
23. BP (flow sheet): 164/107
Pulse 67
TPR (flow sheet): 97.4
Height: __5’7”__ Weight: _270 lb___ (admission sheet/flow sheet)
REVIEW OF SYSTEMS
Write WNL (within normal limits) if normal and describe abnormalities in space provided: (check nurse’s
notes and shift assessments for the latest information regarding your patient)
24. NEUROLOGICAL/MENTAL STATUS: WNL
LOC: alert and oriented to person, place, time (A&O x3), confused, etc. A&O x 3
Motor: ROM x4 extremities WNL
Sensation: 4 extremities WNL
Speech: clear, appropriate/inappropriate speech not
clear but it is appropriate
Pupils: PERRLA WNL
Sensory deficits for WNL
vision/hearing/taste/smell
25. MUSCULOSKELETAL SYSTEM:
Bones, joints, muscles (fractures, contractures,
arthritis, spinal curvatures, etc.):
Extremity circulation checks (pulses, temperature,
sensation, edema):
Ted hose/plexi pulses/compression devices: type
Casts, splint, collar, brace:
26. CARDIOVASCULAR SYSTEM WNL
Pulses (radial, pedal) (to touch
or with Doppler):
WNL
Neck vein (distention):
WNL
Capillary refill (<3seconds):
______yes ______no
Edema, pitting vs. nonpitting:
WNL
Sounds: S1, S2, regular, irregular: WNL
Any chest pain: (describe)
27. RESPIRATORY SYSTEM - patient smokes 1 ½ packs / day for 25 years, admits use of cocaine within last year
Depth, rate, rhythm
Use of accessory muscles:
18:
Use of oxygen: nasal cannual,
mask, trach collar
Cyanosis:
Flow rate of oxygen:
Sputum:
color, amount
Cough: productive
nonproductive
Oxygen humidification:
Pulse oximeter:
__95-96___%
oxygen saturation
(during the day,
89% at night. Pt.
refuses to use
CPAP
Breath sounds:
Clear, rales, wheezes
Clear but diminished
Smoking:
X YES ______no
28. GASTROINTESTINAL SYSTEM:
Abdominal pain, tenderness, guarding, distention, soft, firm:
Ostomy: describe stoma site and stools
Bowel sounds x4 quadrants:
Positive all 4 quadrants
NG tube: describe drainage
Other:
29. SKIN AND WOUNDS:
Color, turgor:
!+ Pallor
Rash, bruises:
Describe wounds (size, location):
Edges approximated:
______yes ______no
Type of wound drains:
Characteristics of drainage:
Dressings (clean, dry,intact):
Sutures, staples, steri-strips, other:
Risk of decubitus ulcer
assessment rating:
Other:
30. EYES, EARS, NOSE, THROAT (EENT): WNL
Eyes: redness, drainage,
edema, ptosis
Ears: drainage
Nose: redness, drainage, edema
Throat: sore
PSYCHOSOCIAL AND CULTURAL ASSESSMENT:
31. Religion preference
(face sheet):
Lutheran
Standardized falls-risk
assessment:
__X_yes ____no
32. Marital status
(face sheet):
Divorced
33. Health-care benefits
and insurance (face sheet):
Medicare
34. Occupation
(face sheet):
unemployed
35. Emotional state
(nurse’s notes):
Anxious, Depressed
Additional information to obtain from clinical units specific to your patient’s diagnosis:
Urinalysis – negative for cultures – no apparent infection
Pressure ulcer
Standardized skin
Standardized nursing
Clinical pathways:
assessment:
assessment:
care plan:
___yes _X__no
__X_yes ___no
___yes _X__no
___yes _X__no
Patient education
_X__yes
___no
Briefly describe the pathophysiology for the medical diagnosis. Explain all relevant data that pertains to that diagnosis (including lab data, diagnostic & other procedures,
medications, assessment, etc). Explain what interventions have been implemented and why.