CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
According to Lier et al 2018, hypovolemic shock is characterized by a reduction of intravascular volume and a subsequent reduction in
preload. According to Bower et al 2018, is a blockage in the small intestine. With increasing distention and pressure within the
intestinal lumen this causes a decrease in venous and arteriolar capillary pressure. This causes edema, congestion,necrosis, and
eventual rupture or perforation of the intestinal wall, with resultant peritonitis.
DIAGNOSTIC TESTS
(REASON FOR TEST AND RESULTS)
PATIENT INFORMATION
Abdominal Xray findings include abnormal Patient SC- admitted 09/06/2021
Quantities of gas,fluid, or both in the
52 year old male
Intestines and collapsed distal bowel.
76 kg,
Confirms small bowel obstruction
allergies: Demerol(skin rash)
Labs(Electrolyte studies, CBC) reveal
Dehydration, loss of plasma volume,
And possible infection
Reveals dehydration and function of liver
And kidneys
ANTICIPATED PHYSICAL
FINDINGS
Signs of dehydration
aching
parched tongue
poor skin turgor
abdominal pain
nausea
ANTICIPATED NURSING INTERVENTIONS
Monitor vital signs and pain level. Administer IV fluids, pain and antiemetic medications as ordered, insert NG tube
As ordered, intermitten suction, collect blood sample for testing , educate patient on diagnosis, pain management,
Medication and side effects, as well as diet and how to avoid small bowel obstruction and irritation of the bowel.
vSim ISBAR ACTIVITY
INTRODUCTION
STUDENT WORKSHEET
Jack Roberts, RN, ED
Your name, position (RN), unit you are
working on
SITUATION
Patient’s name, age, specific reason for visit
BACKGROUND
Patient’s primary diagnosis, date of
admission, current orders for patient
ASSESSMENT
Current pertinent assessment data using head
to toe approach, pertinent diagnostics, vital
signs
RECOMMENDATION
Any orders or recommendations you mayhave
for this patient
Stan Checketts is a 52-year-old male patient presented to the
Emergency Department with complaints of
severe abdominal pain, nausea, and vomiting over
the last few days. The patient has not urinated since yesterday.
The patient complains of severe abdominal pain, nausea and a
distended abdomen. The patient says he has not urinated since
yesterday. Admitted on 9/6/2021. Current orders:Normal saline Iv
bolus 500 ml over 30 minutes. Oxygen to maintain an spo2 of 92%.
ECG Monitoring. Insert an NG tube to lower intermittent suction.
Labs:Complete blood count, abdominal series xray, Meds: morphine
2 mg slow IV push every 4 hours PRN for pain 4-7. Ondansetron 4-8
mg IV push
Poor skin turgor, skin is cold, Dry Mucous membranes, skin is cold to
touch, Patient is on NPO, Distended abdomen, Stomach pains, Has
not urinated since yesterday, Dizziness and weakness.
Vital signs: BP:110/78 HR:130 SPO2:90 on room air Temp: 99 F
Monitoring the patients’ nutritional status. Keep the patient
hydrated to promote fluid balance. Educate the patient on condition
and diet and advise the patient to cut back on caffeine and any
products that may irritate the bowel.
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Morphine
CLASSIFICATION:
Therapeutic: Opioid Analgesic
Pharmacologic: Opioid Agonists/Antagonists
PROTOTYPE: Morphine Sulfate
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
IV: 2 mg IV push every 4 hours for pain 4-7
PURPOSE FOR TAKING THIS MEDICATION
IV: Manages moderate to severe pain
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
1. Educate the patient on the possible side effects such as dizziness, drowsiness, and nausea
2. Advise patient to avoid alcohol and other CNS depressants
Clinical Worksheet
Date: 09/06/2021
Initial:
SC
Student Name: Jack Roberts
Diagnosis:
Severe Dehydration and
Bowel obstruction
HCP: John Doe
Assigned vSim: Stan Checketts
Isolation: N/A
Fall Risk:
Age:52
Consults: GI
Length of Stay:
No
M/F:M
Code Status:
Full Code
IV Type:
Periphe
al
Location:
Peripher
al right
arm
Critical Labs: Complete
blood count: Hb: 20,
HCT:60 and WBC: 17
Electrolytes, Na+: 150, Cl-:
108, BUN:42, Creatinine:
1.9
Other Services: N/A
Consults Needed:
Consult Dietician
Admitted on
Transfer:
09/06/2021
Fluid/Rate: Normal
Saline fluid bolus 500 ml
over 30 min
No
Allergies:
Demerol
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?: Stan Checketts has admitted himself to the hospital for
severe abdominal pain, nausea, and vomiting over the last few days. Upon examination I found that He had poor skin turgor, He has a distended abdomen, He has dry
mucous membranes and has not urinated since yesterday. The patient also stated that he felt “weak and dizzy” all evening. It appears as if the patient has severe
dehydration and bowel obstruction.
Health History/Comorbities (that relate to this hospitalization):
The patient had a hernia repair and apedicectomy multiple years ago.
Shift Goals/ Patient Education Needs:
1. Admnistration of IV fluids
2. Decompression of the bowel through and NG tube
3. Assessing and measuring for fluid and electrolyte imbalance
4. Assessing and measuring the NG output
Clinical Worksheet
Path to Discharge: The patient is able to have a bowel movement without any obstruction.
Path to Death or Injury: Tissue Necrosis, severe dehydration, fluid imbalance.
Alerts:
What are you on alert for with this patient? (Signs & Symptoms)
Management of Care: What needs to be done for this Patient Today?
1.
Abdominal Pain and Discomfort
1. Administer IV fluids as ordered
2.
Nausea/Vomitting
2. Administer medications for pain and nausea as ordered
3. Weakness/dizziness
3. Perform Adbominal assessment
4.Assess and monitor lab values
What Assessments will focus on for this patient?
(How will I identify the above signs &Symptoms?)
5.
Assess and monitor vital signs and pain frequently
1.
Perform an abdominal and pain assessment
6.
Assess patient for signs of dehydration
2.
Assess skin and mucous membranes for signs of dehydration
7.
Ensure patients SPO2 remains above 92% with oxygen
3.
Assess ABGs, CBC, and serum electrolyte lab values
8.
Educate patient on the signs and symptoms of small bowel obstruction and how to avoid
irritation of the bowel.
List Complications may occur related to dx, procedure, comorbidities:
Priorities for Managing the Patient’s Care Today
1. Reducing Abdominal pain
1.
Dehydration
2.
Reducing pain and nausea
2.
Strangulation and tissue necrosis
3.
Insert NG tube for abdominal relief
4.
Improve hydration with IV fluids as ordered
3.
Drowsiness, aching, and a parched toungue and mucous membranes
What nursing or medical interventions may prevent the above Alert or complications?
1.
Administration of IV fluids
2.
Administration of pain and antiemetic medications
3.
Assess for fluid and electrolyte imbalance
4.
Assess for signs of resolution and improvement
What aspects of the patient care can be Delegated and who can do it?
Monitoring client’s status and monitoring for signs of fluid imbalance as well as taking vitalsCAN and LVN
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION:
Ondansetron
CLASSIFICATION:
Therapeutic: Antiemetic
Pharmacologic: 5-HT3 antagonists
PROTOTYPE: N/A
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
IV: 4 mg before induction of anesthesia or postoperatively
PURPOSE FOR TAKING THIS MEDICATION
IV: Prevention of nausea/vomiting postoperatively
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
Educate the patient to notify the nurse if they experience symptoms of irregular heart beat or any involuntary
movements of the eyes, face, or limbs.
References:
Lier, H., Bernhard, M., & Hossfeld, B. (2018). Hypovolämisch-hämorrhagischer Schock [Hypovolemic and hemorrhagic shock]. Der Anaesthesist, 67(3), 225–244.
https://doi.org/10.1007/s00101-018-0411-z
Bower, K. L., Lollar, D. I., Williams, S. L., Adkins, F. C., Luyimbazi, D. T., & Bower, C. E. (2018). Small Bowel Obstruction. The Surgical clinics of North America, 98(5), 945–971.
https://doi.org/10.1016/j.suc.2018.05.007