Med Surg III Concept Map

Pathophysiology

Patho

Enterococci is a bacteria that is normally present in the gut and female genital tract. Vancomycin-resistant enterococci (VRE) is a enterococci bacteria that is resistant to the antibiotic Vancomycin. VRE can cause infections in the urinary tract and potentially cause pyelonephritis and/or enter the blood stream. If found in the blood, this bacteria can cause serious infection and lead to sepsis. Sepsis is a dysregulated host response to infection and can lead to muitliple organ dysfunction syndrome and death. Metabolic encephalopathy occured with this patient due to the systemic inflammation and metabolic dysfunction elicted by sepsis.

S/S of Sepsis: change in LOC, fever, tachycardia, tachypnea, hypotension, paleness

S/S of encephalopathy: AMS, memory loss, fatigue, fainting, problems with coordination, slurred speech, muscle spasms, seizures

Abnormal/Pertinent Labs

Labs

Hgb: 10.7 Norm: 14-18

Hct: 35.2 Norm: 40-52

Potassium: 3.6 Norm: 3.5-5.1

Sodium: 133 Norm: 136-145

WBC: 10.5 Norm: 4.5-11

RBC: 3.79 Norm: 4-5.2

BUN: 11 Norm: 8-23

Albumin: 2.6 Norm: 3.5-5.2

Creatinine: 0.8 Norm: 0.7-1.2

eGFR: 80 Norm: >60

Hgb A1c: 5.6% Norm: 4-6%

Glucose: 105 Norm: 74-109

Troponin: 36 Norm: <15

PTH: 152 Norm: 10-55

Lactate: 1.7 Norm: <2

Toileting Self-Care deficit related to impaired physical mobility, as evidence by, patient is wheelchair bound, incontinent, patient states using one diaper/day, and has recurrent UTIs.

Goal: Patient will discuss barriers to toileting self and formulate a plan for changing brief 5 or more times/day, before patient is discharged.

Problem 1

Interventions:

1. Complete a Lifestyle and Risk Assessment: Toilet facility access and ability to use, including: distance from the bed, chair, and living quarters, characteristics of bed, pathway to toilet, and bathroom.

2. Evaluate the patient's bladder habits: episodes of incontinence, alleviating/aggravating factors, current management strategies

3. Advise the patient about the advantages of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for incontinence.

4. Teach the patient to keep a bladder diary.

Goal was partially met. Further assessment of support at home is needed. Patient understands need for changing brief more often, but it is uncertain whether the patient will be able to meet the goal of changing brief more than 5 times/day without assistance.

Impaired physical mobility related to musculoskeletal impairment associated with spinal surgery, as evidence by, history of lumbar fusion, decreased strength in bilateral lower extremeties, and wheelchair bound.

Goal: Patient will demonstate optimal independence in positioning, exercising, and performing functional activities in bed and in wheelchair in one week.

Problem 2

Interventions:

1. Recognize that components of normal bed mobility include rolling, bridging, scooting, long sitting, and sitting up right. Activity starts with the patient supine, flat in bed, and promotes normal movements that are bilateral, segmenal, well-timed, and involve set positions such as weight bearing and trunk centering.

2. Periodically sit patient upright in bed; dangle patient and/or transfer to wheelchair, if vitals and oxygen saturation levels remain stable.

3. Reassess pain level, especially before movement and/or exercising, and accept patients' pain ratings and levels they think is appropriate for comfort. Administer analgesics based on patients' pain rating.

4. Encourage patient to practice exercises taught by therapists (muscle setting, strengthening, contraction against resistance)

Goal was partially met. Patient able to turn in bed with minimal assistence and continued to work with PT for strengthening. However, patient will likely need more assistance with ADLs when discharged than previously receiving at home to prevent harm.

Acute confusion related to metabolic encephalopathy, as evidence by, altered mental status, forgetfulness, and patient pulling on IV site and tele leads.

Goal: Patient will be free from harm while admitted on Progressive Care.

Problem 3

Interventions:

1. Provide reality orientation, including identifying self by name at each encounter with the patient and gently reorient patient.

2. Assess for impulsive symptoms and maintain increased surveillance of patient.

3. Implement fall risk screening and precautions.

4. Assess for and report possible physiological alterations such as sepsis, electrolyte imbalance, use of medication with known cognitive side effects, hypogylcemia, hypoxia.

Goal was met. Patient was reoriented throughout shift, fall precautions in place, frequent rounding, and assessment ensured patient remained free of harm while admitted.

Risk for shock related to sepsis, as evidence by, recent history of sepsis, recent history of phyelonephritis and recurrent UTIs.

Goal: Maintain adherence to agreed-on medication regiments during hospital stay.

Potential Problem 1

Interventions:

1. maintain IV access, provide isotonic fluids (NS) as ordered and administer antibiotics on time.

2. monitor ABGs, serum glucose, lactate levels, renal function

3. monitor circulatory status ( BP, HR, pulses, skin color, skin temp, pulse ox, LOC)

4. educate patient and family on disease process and rationals of medications.

Goal was met. Patient recieved prescribed doses of antibiotic during hospital stay, IV access was maintained, and patient education was provided.

Risk for impaired skin integrity, related to impaired physical mobility and excessive moisture, as evidence by, patient limited to hospital bed and wheelchair, incontinence, and patient stating she changes her diaper once/day.

Goal: Patient will demonstrate understanding of personal risk factors for impaired skin integrity before discharge.

Potential Problem 2

Interventions:

1. Inspect and monitor skin condition for color, texture, redness, localized heat, edema, pressure damage, or lesions. Determine whether patient is experiencing loss of sensation or pain.

2. Develop a patient-specific prevention plan; use of barrier creams, keep skin clean and dry, and frequently reposition patient, alternating sides.

3. Implement and communicate patient-specific prevention plan. Educate patient on rationales and encourage patient to paticipate in prevention plan.

4. Teach patient to use pillows or wedges for effective turning and more comfortable repositioning.

Goal was partially met. Skin kept clean and dry and patient frequently repostioned with minimal assistance. Education was provided however patient was intermittently confused and forgetful. Education should be repeated when patient returns to baseline mental status.