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Concept Map #1

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by

Corrine Henson

on 22 November 2015

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Transcript of Concept Map #1

Concept Map #1 by Corrine Henson
Pathophysiology of Medical Diagnosis
Crohn's disease is a chronic inflammatory disorder of the gastrointestinal tract. It can occur at any point within the tract from the mouth to the anus. Patients with Crohn's disease often experience relapsing episodes. The course of progression tends to occur at the terminal ileum as well as the ascending colon. Fissures and ulcers may occur and bowel mucosa leading to the bowel walls becoming fibrotic and thickened. When inflammation occurs, the tract may become obstructed. Inflammation may "skip," and sometimes there may be normal areas along the tract in-between Crohn's areas. As a result, patients experience malnutrition and malabsorption.

Manifestations of Crohn
'
s disease include
:
continuous or episodic diarrhea
abdominal pain and tenderness
palpable RLQ mass
fever, fatigue, malaise, weight loss
nausea, vomiting, and epigastric pain
anemia
constipation (with obstruction)
Nursing Diagnosis
Risk for infection related to chronic disease
[Crohn's disease diagnosed at age 17],
inadequate primary defenses
[broken skin: surgical procedure],
traumatized tissue
[broken skin: surgical procedure],
inadequate secondary defenses
[decreased hemoglobin (8.3 g/dL)],
and undergoing an invasive procedure
[hemicolectomy on 09/15/2015]. (Ackley & Ladwig, 2014)
History and Physical
Nursing Diagnosis
Imbalanced nutrition: less than body requirements related to inability to absorb nutrients
[Crohn's disease diagnosed at age 17],
inability to digest food
,
and an inability to ingest food
[patient's current NPO status post hemicolectomy]
as evidenced by aversion to eating, lack of food, and pale mucous membranes
. (Ackley & Ladwig, 2014)
Nursing Assessment
Nursing Interventions
Expected Outcomes
History
: 26-year-old female with a history of Crohn's disease diagnosed at age 17. The patient presented to ED with complaint of abdominal pain, nausea, vomiting and PO intolerance. Colonoscopy in 02/2015 revealed friability and ulceration at ileocecal valve with scattered ulcers in TI. CT in 07/2015 showed 12cm long mural thickening. Patient underwent
right hemicoloectomy
on 9/15/2015. Other than colonoscopy, no previous surgeries, hospitalizations, or psychiatric history are mentioned in the chart.
Following ambulation in the hallway, the patient's vital signs revealed:

Blood pressure
: 122/70 mmHg
Heart rate
: 84 bpm
Respirations
: 16 breaths per minute
Temperature
: 38.9° C
Pulse Ox
P: 95% RA

The patient did not have any complaint of shortness of breath or chest pain, however she stated she was "hot," and was visibly sweating.
1. Observe and report signs of infection such as redness, warmth, and increased body temperature. (Rationale:
Evidence-based practice states that a change in mental status, fever, shaking, chills, and hypotension are indicators of sepsis
.) (Ackley & Ladwig, 2014).
2. Assess temperature of clients: report a single temperature of greater than 100.5° F. (Rationale:
Evidence-based practice states that fever is often the first sign of an infection. The progression of an infection may be rapid and can become life-threatening. Report temperature elevation from baseline
.) (Ackley & Ladwig, 2014).
3. Encourage early ambulation and deep breathing. (Rationale:
Early ambulation and deep breathing aids in clearing the lungs and aims to prevent pneumonia
.) (Ackley & Ladwig, 2014).
1. The patient will remain free of symptoms of infection throughout the post-surgical recovery period during the hospital stay. (Ackley & Ladwig, 2014).

2. The patient will demonstrate appropriate hygienic measures such as handwashing throughout the post-surgical recovery period during the hospital stay. (Ackley & Ladwig, 2014).

3. The patient will demonstrate compliance of pulmonary toileting at least 10x per hour into a spirometer throughout the post-surgical recovery period during the hospital stay. (Ackley & Ladwig, 2014).
Laboratory Results
RBC
: 2.97 M/cu mm (
Low
)
Hemoglobin
: 8.3 g/dL (
Low
)
Hematocrit
: 25.5% (
Low
)
Glucose
: 108 mg/dL (
High
)
Urea
-
nitrogen
: 6 mg/dL (
Low
)
Calcium
: 7.8 mg/dL (
Low
)
RBC
: 2.97 M/cu mm (
Low
) (Female: 4.0-5.20 M/cu mm)
The patient is 1-day postoperative on the day of care and due to surgery, a decreased RBC count is a result of blood loss during surgery. Also, the patient is NPO and malnourished thus low RBC can be indicative of dietary deficiency. A chronic illness may also contribute to a low RBC level in which this case, the patient's medical history of Crohn's disease would be a comorbidity of anemia.
Hemoglobin
: 8.3 g/dL (
Low
) (Female: 12-15 g/dL)
The patient is 1-day postoperative on the day of care and due to surgery, a decreased hemoglobin is a result of blood loss during surgery.
Hematocrit
: 25.5% (
Low
) (Female: 36%-46%)
Hematocrit reflects RBC and hemoglobin levels. Similar to that of hemoglobin, the patient is 1-day postoperative on the day of care and due to surgery, a low hematocrit is a result of blood loss during surgery.
Glucose
: 108 mg/dL (
High
) (Adult fasting: 60-99 mg/dL)
It is possible this patient is experiencing impaired fasting glucose as a result stress response from anesthesia from surgery. She is also receiving D5 1/2 +20K which causes increased serum glucose.
Urea
-
nitrogen
: 6 mg/dL (
Low
) (Adult: 7-22 mg/dL)
The patient is NPO with NGT to LCWS. This patient is currently malnourished.
Calcium
: 7.8 mg/dL (
Low
) (Adult: 8.4-10.5 mg/dL)
The patient has a history of Crohn's disease causing intestinal malabsorption. She is also s/p hemicolectomy which places her at greater risk for malabsorption. She is currently NPO and malnourished.
Medications
Prior to hospitalization, the admission note states the patient is not taking any home medications. Currently the patient is NPO and is receiving IV fluids along with PCA for pain management. She is refusing lidocaine patch.
Fentanyl PCA
D5 1/2 + 20K
Ondansetron
Lidocaine
Class
: Narcotic analgesic
Therapeutic action
: Analgesia for moderate to severe pain as well as sedation
MOA
: Synthetic, potent narcotic agonist analgesic that causes analgesia and sedation; alters respiratory rate and alveolar ventilation
Contraindications
: Patients who have received MAOI within 14 days; substance abuse history; significant respiratory compromise (acute or severe bronchial asthma); patients who have or are suspected of paralytic ileus
Common side effects
: Sedation and nausea are common; life threatening side effects include circulatory depression, cardiac arrest, respiratory depression or arrest
Safe dosage
: IV 2-20 mcg/kg (patient receiving 0/20/10/6)
Nursing implications
: Monitor VS (
especially respiratory rate!
)
Patient education
: Remind patient and family that only the patient may use PCA.
Class
: Fluid replacement (water, electrolytes, and calories)
Therapeutic action
: Fluid and electrolyte replacement, glucose regulation in patients postoperatively and remaining NPO
MOA
: Fluid and electrolyte replacement, glucose regulation in patients postoperatively and remaining NPO
Contraindications
: Caution use in CHF patients, renal insufficiency
Common side effects
: Hyperglycemia
Safe dosage
: Patient was receiving D5 1/2 + 20K @ 84 mL/hr
Nursing implications
: Monitor for hyperglycemia, monitor blood glucose level, monitor serum potassium, monitor for fluid overload
Patient education
: Teach patient to report febrile response.
Class
: 5-HT3 antagonist, antiemetic
Therapeutic action
: Prevents nausea and vomiting associated with anesthesia
MOA
: Blocks the release of serotonin from the wall of the small intestine to prevent nausea and vomiting
Contraindications
: Hypersensitivity; patients following abdominal surgery may mask paralytic ileus
Common side effects
: Headache, sedation, diarrhea
Safe dosage
: 4 mg IM/IV
Nursing implications
: Monitor electrolytes (diarrhea: electrolyte imbalance)
Patient education
: Teach patients and families that headache requiring analgesia for relief is a common adverse effect.
Class
: Local anesthetic
Therapeutic action
: Pain relief
MOA
: Decreases pain through a reversible nerve conduction blockade
Contraindications
: Hypersensitivity
Common side effects
: Site of application may develop erythema or edema
Safe dosage
: Topical patch for use up to 12h per 24h period
Nursing implications
: Do not apply to large areas of skin or to broken or abraded surfaces.
Patient education
: Teach patients that topical patches may only be applied for use of up to 12h per 24h periods.
Nursing Assessment
Nursing Interventions
Expected Outcomes
Nursing Diagnosis
Nursing Assessment
Nursing Interventions
Expected Outcomes
Risk for falls related to environment
[dimly lit room, unfamiliar room],
medications
[narcotic: the patient is on Fentanyl PCA];
anemia
[the patient has low Hgb and low Hct];
impaired physical mobility
[status post hemicolectomy];
and postoperative conditions
[status post hemicolectomy]. (Ackley & Ladwig, 2014)
1. The patient will progressively gain weight toward a desired goal in an effort to weigh within a normal range for her height and age. (Ackley & Ladwig, 2014).

2. The patient will identify nutritional requirements related to living with Crohn's disease prior to discharge. (Ackley & Ladwig, 2014).

3. The patient will consume adequate nourishment via peripheral parenteral nutrition until her meal plan is advanced and tolerated during the hospital stay. (Ackley & Ladwig, 2014).

4. The patient will be free of signs of malnutrition prior to discharge. (Ackley & Ladwig, 2014).
1. Recognize that clients with acute disease or injury-related malnutrition, wounds, recent surgery, trauma, and a fever are using more calories and need increased calories to maintain their nutritional status. (Ackley & Ladwig, 2014).
2. Recognize that clients with chronic disease-related malnutrition (
the patient's history of Crohn's disease
) may need calories to maintain nutritional status. (Ackley & Ladwig, 2014).
3. Recognize that severe protein-calorie malnutrition can result in septicemia from impairment of the immune system, and organ failure including heart failure, liver failure, and respiratory dysfunction, especially in the critcally ill client. (Rationale:
Untreated malnutrition can result in multiple organ failure and death
.) (Ackley & Ladwig, 2014).
4. Watch carefully for signs of infection and maintain every action possible to protect the client from infection. (Rationale:
Protein-energy malnutrition is associated with a significant decrease in immunity; there is a decrease in leukocytes, lymphocytes, and the overall function of the immune system
.) (Ackley & Ladwig, 2014).
5. Recognize the need to begin enteral feedings within 24 to 48 hours of entrance into the critical care environment, once the client is free of hemodynamic compromise, if the client is unable to eat. (Rationale:
Providing nutrition early helps maintain muscle and immune system function, lower infection rate, decrease gut permeability, decrease incidence of multiple organ failure, aid wound healing, and reduce hospital length of stay
.) (Ackley & Ladwig, 2014).
Abdominal pain on admission to ED
Pale mucous membranes on examination
Aversion to eating due to inability to tolerate PO
NPO status post hemicolectomy
History of Crohn's disease (diagnosed at the age of 17) which places her at an
increased
risk for malnutrition following surgery due to malabsorption of nutrients
Nutritonal screening
:
Weight: 48.8 kg (107.4 lbs)
BMI: 17.373 (BMI of less than 20 may indicate malnutrition)
Rationale for screening:
Research has shown that from 23% to 50% of all clients are malnourished on admission, and the presence of malnutrition increased the length of hospital stay
. (Ackley & Ladwig, 2014).
1. Carefully assist a mostly immobile client up. Be sure to lock the bed and have sufficient personnel to protect the client from falls. When rising from a lying position, have the client change positions slowly, dangle legs, and stand next to the bed prior to walking to prevent orthostatic hypotension. (Ackley & Ladwig, 2014).
2. Evaluate the client's medications to determine whether medications increase the risk of falling. (Rationale:
Polypharmacy has been associated with increased falls. Medications such as sedatives increase the risk for falls
.) (Gray-Miceli & Quigley, 2011). (Ackley & Ladwig, 2014).
3. Orient the client to environment. Place the call light within reach and show how to call for assistance; answer the call light promptly. (Ackley & Ladwig, 2014).
4. Routinely assist the client with toileting on her own schedule. Keep the path to the bathroom clear, label the bathroom, and leave the door open. (Rationale:
A study found that falls were most commonly associated with toileting, especially falling on the way from bed or chair to the bathroom
.) (Tzeng, 2010). (Ackley & Ladwig, 2014).
1. The patient will remain free of falls throughout the hospital stay. (Ackley & Ladwig, 2014).

2. The patient will take measures to change the hospital room environment to promote safety to minimize the incidence of falls throughout the hospital stay. (Ackley & Ladwig, 2014).

3. The patient will verbalize understanding of methods useful to prevent falls-related injury throughout the hospital stay. (Ackley & Ladwig, 2014).
Narcotic analgesic: Fentanyl PCA
Labs indicating anemia related to blood loss:
Hemoglobin: 8.3 g/dL
Hematocrit: 25.5%
Status post hemicolectomy
Nursing Diagnosis
Nursing Assessment
Nursing Interventions
Expected Outcomes
Risk for shock related to emergency procedures related to traumatic events
[status post hemicolectomy];
hypovolemia
;
systemic inflammatory response syndrome
. (Ackley & Ladwig, 2014)
Risk factors
:
Primary disease: Crohn's disease
Surgical procedure: status post hemicolectomy
Immunosuppression as patient is postop day one
Dehydration as patient is NPO
Assessment
:
Blood pressure: 122/70 mmHg
Heart rate: 84 bpm
Respirations: 16 breaths/minute
Temperature: 38.9° C
Pulse Ox: 95% RA
Skin: Pale, clammy - visibly sweating
1. Complete a full nursing assessment. (Rationale:
A full nursing physical assessment is crucial in identifying all factors that might place the client at risk for development of shock, such as hypoperfusion of internal organs or tissue hypoperfusion
. (Ackley & Ladwig, 2014).
2. Monitor circulatory status (e.g. BP, MAP, skin color, skin temperature, heart sounds, heart rate and rhythm, presence and quality of peripheral pulses, and pulse oximetry). (Rationale:
The initial phase of shock is characterized by decreased cardiac output and tissue perfusion which results in immediate compensatory changes evidenced by changes in blood pressure, increased heart rate, and shunting of blood away from the periphery, resulting in pale, cooler, damp skin, with reduced peripheral pulses
. (Dufalt et al, 2008; Pinsky, 2011). (Ackley & Ladwig, 2014).
3. Maintain vital signs and pulse oximetry within normal parameters. (Rationale:
Increased heart rate (above 90 beats/minute), hypotension (BP below 90 mmHg systolic), tachypnea (greater than 20 breaths/minute), hypoxia (SpO2 below 90%), and lactate levels (above 2 mmol/L) are indicators of shock
.
Temperature greater than 38 C or less than 36 C with white blood cell count greater tan 12,000/mm3 or less than 4000/mm3 plus symptoms listed earlier are indicators of SIRS
. (Dellinger et al, 2008; Wilmont, 2010). (Ackley & Ladwig, 2014).
4. Monitor hydration status including skin turgor, daily weights, postural blood pressure changes, serum electrolytes, and intake and output. (Rationale:
Daily weights are an important indicator of fluid status. Skin turgor is a measure of hydration as are intake and output. Serum electrolytes monitor fluid status
.) (Ackley & Ladwig, 2014).
5. Encourage early ambulation and deep breathing. (Rationale:
Early ambulation and deep breathing aids in clearing the lungs and aims to prevent pneumonia
.) (Ackley & Ladwig, 2014).
1. The patient will maintain adherence to agreed upon medication regimens to prevent complications of infection throughout the hospital stay. (Ackley & Ladwig, 2014).

2. The patient will be verbalize understanding of monitoring for infection signs and symptoms and will report them to the health care provider immediately throughout the hospital stay. (Ackley & Ladwig, 2014).

3. The patient will maintain urine output greater than 05 mL/kg/hr throughout the hospital stay. (Ackley & Ladwig, 2014).

4. The patient will maintain normal vital signs and pulse oximetry throughout the hospital stay. (Ackley & Ladwig, 2014).

5. The patient will maintain warm, dry skin throughout the hospital stay. (Ackley & Ladwig, 2014).
References
Ackley, B. J., & Ladwig, G. B. (2014).
Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
(10th ed.). Maryland Heights, Missouri: Mosby Elsevier.
LeMone, P., Burke, K., & Bauldoff, G. (2012).
Clinical Handbook for Medical-Surgical Nursing: Critical Thinking in Patient Care
(5th ed.). Upper Saddle River, New Jersey: Pearson.
Pagana, K. D., & Pagana, T. J. (2011).
Mosby's Diagnostic & Laboratory Test Reference
(11th ed.). St. Louis, Missouri: Elsevier.
Wilson, BSN, MSN, PhD, B. A., Shannon, BSN, MSN, PhD, M. T., & Shields, PharmD, K. M. (2015).
Pearson Nurse's Drug Guide 2015
. Upper Saddle River, New Jersey: Pearson Education, Inc.
Diagnostic tests to diagnose Crohn's disease
:
Colonoscopy to biopsy the bowel mucosa
Upper GI series to show changes (ulcerations, strictures, fistulas)
CBC to detect anemia
Sedimentation rate is elevated indicating inflammatory response
Albumin and vitamins: decreased as patients with Crohn's are malnourished due to malabsorption of the vital nutrients leading to protein loss and chronic inflammation
Laboratary Results
Patient Education Related to Crohn's Disease and Post-surgical Recovery
1. Teach the patient the importance of rest to reduce stress as stress can cause an inflammatory response related to Crohn's disease (LeMone, Burke, & Bauldoff, 2012).
2. Teach the patient dietary guidelines related to Crohn's disease. This includes high kilocalorie, high protein, and low fat with restricted dairy intake. The patient should also be encouraged to avoid caffeine and alcohol. This will provide relief from experiencing an inflammatory response related to Crohn's disease (LeMone, Burke, & Bauldoff, 2012).
3. Teach the patient the importance of using the incentive spirometer throughout the recovery period to decrease the risk of fluid accumulation in the lungs that would delay recovery (Ackley & Ladwig, 2014).
4. Encourage the patient to ambulate often to promote a healthy post-surgical recovery (Ackley & Ladwig, 2014).
(LeMone, Burke, & Bauldoff, 2012)
(Wilson, BSN, MSN, PhD, Shannon, BSN, MSN, PhD, & Shields, PharmD, 2015)
(Wilson, BSN, MSN, PhD, Shannon, BSN, MSN, PhD, & Shields, PharmD, 2015)
(Wilson, BSN, MSN, PhD, Shannon, BSN, MSN, PhD, & Shields, PharmD, 2015)
(Wilson, BSN, MSN, PhD, Shannon, BSN, MSN, PhD, & Shields, PharmD, 2015)
(Pagana & Pagana, 2011)
Right Hemicolectomy
A hemicolectomy is a surgical procedure (also known as a resection) in which a portion of the patient's ascending colon was removed. Following removal, the surgeon then reattaches the small intestine to the rest of the colon. In this patient's situation, the hemicolectomy was performed as a result of ulceration at the ileocecal valve as well as thickening along the walls of the colon.
Thickening can occur due to inflammation along the tract which is a complication of Crohn's disease. Hemicolectomy does not cure Crohn's disease, it only aids in removing the diseased portions along the colon.
Google images
Physical assessment
:
A&Ox3, 36.9° C
Regular rate and rhythm of 86 bpm
119/63 mmHg
Clear lung sounds bilaterally, 100% on RA
Abdomen soft, flat, non-distended, tender
Warm skin, no presence of edema
Impaired skin integrity:
ML incision with gauze, CDI
Laparoscopic sites x2 with dermabond- open to air and CDI
Voids CYU
NGT to low continuous wall suction, NPO
Full transcript