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
Findings-include assessment, labs and dx
System
tests
A&Ox3
Neuro
Sensory function – WNL
Cardiac
Resp
GI
GU
Motor function – WNL
No seizure or tremors No assessment changes 2nd day
Hx of CAD, PVD, HTN, MI x5
T: 98.2 BP: 118/64 P: 71
T: 98.8 BP: 111/46 P: 71
Apical pulse: 78, 3/9/06: 84
Radial and dorsalis pedal pulses: weak, regular
(L) foot: anterior localized edema, 1+ nonpitting
BUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia,
dehydration, CHF, MI, renal disease
RBC 3.20 (normal female: 4.2-5.4) indicates anemia,
dietary deficiency and renal failure
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,
dietary deficiency, kidney disease
Hct 27.4% (normal female 37-47%) indicates anemia,
dietary deficiency
K+ WNL
No other assessment changes 2nd day
R: 20 R: 18 Pt on room air O2 sat: 97%
Lung sounds clear
No cough No SOB
Non-smoker No other assessment changes 2nd day
Abdomen: soft, nontender to touch
Bowel sounds x4
LBM: 3/4/06
Intermittent abdominal pain: “6 out of 10”, sharp, dull
Intermittent nausea, no vomiting noted
3/8/06: clear liquid diet 3/9/06: 1800 ADA
Usual bowel pattern: once q 3 days
3/9/06: pt stated she had small amt of diarrhea previous
evening.
RBC 3.20 (normal female: 4.2-5.4) indicates anemia,
dietary deficiency and renal failure
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,
dietary deficiency, kidney disease
Hct 27.4% (normal female 37-47%) indicates anemia,
dietary deficiency
Albumin 2.8g/dl (normal: 3.5-5g/dl) indicates malnutrition,
inflammatory disease
Prerenal azotemia
Pt voids in bathroom
No I&O ordered
No bladder distention noted
No c/o urgency or hesitation
Pathology explanation
Nursing implications-include
medications and teaching
WNL
Continue to assess and monitor q shift and prn for
mental status changes or other neuro changes.
Coronary artery disease – atherosclerosis is
major cause of CAD, the vessel lumen narrows
and restricts blood flow and inadequate
oxygenation of myocardial tissues occur – this
can cause decreased peripheral pulses.
Myocardial infarction – myocardial tissue is
severely deprived of O2 and ischemia develops
which can lead to necrosis of the tissues.
PVD – arterial occlusion deprives the lower
extremities of O2 and nutrients – this can cause
decreased pedal pulses.
Encourage pt to maintain a minimum fluid intake of
1500ml/day (7a-3p 600ml / 3p-11p 600ml / 11p-7a
300ml) Consult MD if pt is on diuretics and
experiences significant weight loss (>2lb/day or
5lb/wk), weigh pt daily. Place pt in semi- to high
Fowlers position to decrease cardiac workload.
Instruct pt to avoid straining (b/c of constipation,
holding breath while moving up in bed). Encourage
deep breathing exercises to supply adequate O2 to
tissues. Administer medications as prescribed.
Digoxin 0.125mg PO qd
Lotrel 5-10 PO q AM
Plavix 75mg PO qd
Lotensin 10mg PO q AM
Lasix 20mg PO q AM
Isordil 20mg PO TID
WNL
Continue to assess V/S q shift and lung sounds
Diverticulitis is inflammation of the diverticula in
the intestinal walls. Infection results from food
and/or bacteria that become trapped in the
diverticulum. This is caused by not enough fiber
in the diet, and constipation 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 to
2500cc/day (7a-3p 1100cc, 3p-11p 1100cc, 11p-7a
300cc). Encourage hot liquids in the mornings
(coffee, tea). Administer laxatives/stool softeners as
ordered. Administer pain meds as ordered.
Administer antiemetics as ordered.
Reglan 10mg PO AC
Zofran 4mg IV PRN q4-q6 for nausea/vomiting
Demerol 25mg IV q4 PRN for pain
Kaon-CL (KCL) 10mEq PO qAM
Neurotin 300mg PO TID (unlabeled use: chronic pain)
Azotemia is excess urea and nitrogenous wastes
in the bloodstream due to kidney insufficiency and
is caused by conditions that reduce blood flow to
the kidneys. These conditions include prolonged
vomiting, 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
hypovolemia which results in decreased cardiac
output.
Musc-skel
Integ
Endocrine
Psychosocial
RBC 3.20 (normal female: 4.2-5.4) indicates anemia,
dietary deficiency and renal failure
Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia,
dietary deficiency, kidney disease
BUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia,
dehydration, CHF, MI, renal disease/failure
Crea: WNL
K+ WNL
No assessment changes 2nd day
Limb movements x4 WNL
No c/o pain/stiffness
Pt sits, walks, stands and turns independently
Posture/gait: WNL
No assessment changes 2nd day
Skin warm and dry
Skin intact
(L) foot: anterior localized edema, 1+ nonpitting
No assessment changes 2nd day
Glucose:
3/7/06: 223
3/8/06: 150
3/9/06: 119
azotemia, you need to correct the source of the
problem, which is reduced blood flow.
Place pt in semi- high Fowlers position to reduce
cardiac workload, instruct pt to avoid straining.
Promote physical and emotional rest. Encourage
deep breathing for adequate tissue oxygenation.
Kaon-CL (KCL) 10meq PO qAM
WNL
Continue to monitor for any problems with walking or
pain q shift/prn.
Edema due to cardiovascular problems as stated
above.
Continue to assess and monitor edema and skin for
any changes q shift and prn.
DM type 2 is due to insulin resistance of the cells
response, or the pancreas doesn’t produce
enough insulin and this affects protein,
carbohydrate and fat metabolism.
Pt has family/friends that visit. She lives alone. She does
not drink alcohol. She is knowledgeable about her
medical hx conditions, though she seems to lack
knowledge regarding nutrition. She suffers from insomnia
sometimes.
Nutrition problems in the elderly can be common,
could be due to financial resources or knowledge
deficit on nutrition facts.
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 HS
Novolin 70/30 SC BID AC 35units
Assess reasons for nutrition deficit. If financial, refer
pt to sources (ex: Lone Star program), if knowledge
deficit, pt needs teaching on her nutrition. Encourage
family 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.
2.
3.
4.
5.
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.
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.
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
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.
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)
Author Unknown