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NURSING CONCEPT MAP
Transcript of NURSING CONCEPT MAP
Subjective: Dull back pain intensity rated 5/10. Mild nausea. Difficulty and pain with chewing.
#1 Acute pain - Pt will report pain down to his comfort level (3/10) by the end of this shift.
#2 Imbalanced nutrition - Pt will tolerate oral feedings without adverse effects this shift.
#3 Risk for injury - By the end of this shift, pt will be free from injury.
Vital Signs at 9am:
SpO2 97% on 2L O2
NURSING CONCEPT MAP
Lab Results (as of 9/20/2015)
WBC 5.8 (12.7 on 9/18)
(+) Pseudomonas Aeruginosa
Vanco 1G IV every 12 hours
Cefepime 1G IV every 8 hours
Tylenol 500mg PO every 6 hours PRN
Interpersonal - Roll expectations
Intrapersonal - Infection, pain, nutritional level, deteriorating physical ability
Extrapersonal - Isolation room environment
- Left nephrostomy tube CDI, draining dark teacolored urine, cloudy and foul smelling, total urine output is 50mL. Grimmacing, eyes lack luster, narrowed focus including withdrawl from social contact.
- Pt with poor nutrition, needs assistance with feeding, hypoactive bowel sounds, incontinent of bowel and bladder. Last BM 9/20/15. Skin is dry and with stage 1 pressure ulcer on sacrum. Blisters on right foot arch and right groin.
- Alert and oriented to self only, knows his wife and daughters. Forgetful but able to express basic needs know, chair bound and both upper and lower extremities are weak. Max assist of 2 using the hoyer lift.
#1 Acute pain related to inflammation and infection of the urethra, bladder and other urinary tract structures.
#2 Imbalanced nutrition, less than body requirements related to insufficient oral intake
#3 At risk for injury related to impaired judgement and weakness
#1 Acute Pain:
1 - Assess the intensity, location and factors that aggrivate or relive pain.
Rationale: To help the pt achieve effective pain management by advocating for proper control. (Ignatavicius p 40)
2 - Assess pts s/s of pain and administer pain medication as prescribed.
Rationale: Assement allows for care plan modification as needed. (Sparks p 236)
3 - Plan activities with pt to provide distraction such as Television and visits.
Rationale: To help pt focus on non pain related matters. (Sparks p 236)
4 - Frequent incontinence and perineal care, provide routine nephrostomy tube care and monitor for complications such as bleeding at the site or through the tube and for infection.
Rationale: To prevent contamination of the urethra and reduce the risk of cystitis and other UTI's. (Ignatavicius p 1493)
5 - Schedule a follow-up appointment after the completion of the medications. At the follow-up visit another urine sample may be taken for analysis or culture.
Rationale: it is recommended that results of the urine test should be checked for sensitivity in the 48 hours follow-up, which should include checking for imporvement of symptoms because this will lead to a clinical diagnosis and imperical treatment. (Armstrong p 4)
6 - You may use home therapy treatments such as cranberry juice/capsules
Ratioinale: The use of cranberry has been the most promising agent at reducing recurrent rates of UTI's in the elderly population (Matthews p 301)
#1 Acute Pain
1 - Partially met. On assessment pt is able to report 5/10 dull back pain at the beginning of the shift, but unable to articulate factors that intensify or relieve pain. Pt was withdrawing from questions asked.
2 - Partially met. Pt refused pain medication when offered, alternative pain control measure rendered such as positioning and pt stated he felt more comfortable after and he even had an hour nap without disturbance.
3 - Met. Pt was watching his favorite show and had a visit from his wife and daughter. Observed pt and he appears happier and interactive when the family is around.
4 - Met. Incontinence and perineal care was provided every 2 hours and as needed, no worsening noted on sacral ulcer. The dressing on the nephrostomy site remains CDI, and no microscopic blood noted in drainage bag.
5 - Partially met. Daughter plans to make follow-up appointment with the Doctor.
6 - Partially met. Family stated "that is very interesting about the cranbery juice/capsules and I will get that for Dad to try as soon as he is discharged."
#2 Nutrition Imbalance
1 - Provide a diet prescribed for pt's specific condition
Rationale: To improve pts nutritional status. (Sparks p 218)
2 - Monitor electrolyte levles and report abnormal values.
Rationale: Poor nutritional status amy cause electrolyte imbalances. (Sparks p 218)
3 - Refer pt to a dietician for dietary management.
Rationale: Dietician can help pt and healthcare team to individualize pts diet within prescribed restrictions.
(Sparks p 218)
4 - Provide or assist with oral hygiene.
Rationale: To help pt remain comfortable (Sparks p 219)
5 - Involve family members in meal planning.
Rationale: To encourage them to help pt increase oral intake. (Sparks p 219)
#2 Nutrition Imbalance
1 - Not met. Pt consumed only 25% of food served on breakfast and lunch tray.
2 - Not met. No labs drawn from today, but previous day lab values are all within normal values.
3 - Met. You collaborated with primary nurse and agreed to recommendation.
4 - Met. Provided good oral care in the morning with am care and pt stated he felt much better after the oral care.
5 - Met. Wife mentioned a few food preferences for the pt that could improve his appetite.
#3 Risk for Injury
1 - Orient pt to environment. Assess pts ability to use call bell and bed positioning controls. Keep bed at lowest level.
Rationale: These measures will help pt cope with unfamiliar surroundings. (Sparks p 179)
2 - Help pt and family identify situations and hazards that can cause accidents.
Rationale: To increase awareness of potential dangers. (Sparks p 179)
3 - Help the pt to get oob to chair if needed; lock all equipment, such as bed and chair breaks before transferring pt.
Rationale: To reduce the risk of pt harm resulting from falls. (Ignatavicius p 27)
4 - Arrange the furniture in pts room to eliminate clutter or obstacles that could contribute to a fall.
Rationale: To decrease potential for injury. (Ignatavicius p 27)
5 - Observe for side effects and toxic effects of drug therapy.
Rationale: Drug therapy is a factor that can ause delirium.. (Ignatavicius p 23)
6 - Have PT assess the pt for mobility and safety.
Rationale: Collaboration with other members of the health care team is one intervention for preventing falls.
#3 Risk for injury
1 - Not met. Pt has dementia and is forgetful to environment and current situation, although he is able to demonstrate how to use the call bell when instructed.
2 - Met. Family expresssed their awareness of safety precautions in their surroundings at home.
3 - Met. Assisted PT to get pt oob to chair with the hoyer lift. Pt remains safe with no inury noted.
4 - Met. The room was free of clutter the whole sihift. Even the family was cooperative with the plan of care. Observed daughter making sure things were in their proper place and not in the way.
5 - Partially met. Pt showed no signs or symptoms of increase in confusion, restlessness, dizziness or any adverse effects that could injure the pt.
6 - Met. Evaluation and treatment was done by the Physical Theraphy department.
1 - Estabilsh rapport to gain trust between pt and nurse. This could help ensure compliance with administration of pain medication.
2 - Bladder training by offering the urinal every 2 hours, even if the pt does not have th urge to urinate.
#2 Nutrition Imbalanced
1 - Encourage family to have meals with pt to help increase appetite.
2 - Recommend to Doctor to start IV fluids if appetite does not improve or decreases.
3 - Determine pts food likes and if they are not available in the hospital have family bring in foods from home being compliant with current diet.
#3 Risk for Injury
1 - Referral to Out patient PT and OT to help improve or restore pts physical function and enhance self esteem.
2 - Encourage family and care giver to increase self care activities as tolerated.
Matthews, S.J., Lancaster, J.W.Urinary tract infections in the elderly population. The American Journal of Geriatric Pharmacotherapy. October 2011 286-309
Armstrong, K. Diagnosing and treating urinary tract infections in older people. British Journal of Community Nursing.
Ralph, S.S., Taylor, C.M., Nursing diagnosis reference manual 9th ed. 2014
Ignatavacius, D.D., Workman, M.L. Medical surgical nursing patient centered collaborative care 7th ed. 2013