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Concept Map Presentation

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by

Katie Przybysz

on 29 April 2013

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Transcript of Concept Map Presentation

Patient Assessment -Pt SpO2 level in low 80's on room air Past Medical History -ARF
-CAD
-COPD
-CHF
-HTN
-TIA
-A-FIB
-UTI Nursing Diagnosis Nursing Diagnosis Impaired gas exchange R/T ventilation perfusion inequality secondary to COPD AMB by pt SpO2 @ 84% on room air and exertional dyspnea (Ackley & Ladwig, 2011). Current Medical Diagnoses -Renal Insufficiency -Pt has continuous bleeding (>36hr) at incision site of tunneled cath -Pt has pain at incision site -CHF exacerbation -COPD exacerbation -Dehydration -UTI -Hypernatremia -Hematuria -Pt is anxious -Pt has low H&H values
-Hemoglobin 9.0 (13.5-16.7)
-Hematocrit 26.2 (40-49) -Pt on Warfarin anti-coagulant therapy -Hypercholesterolemia
-Malignant neoplasm of R breast
-Borderline diabetic
-Valvular heart disease
-Mechanical heart valve
-Pulmonary HTN
-Warfarin anti-coagulant therapy
-Atrial valve regurgitation Medications -Coreg
-Pepcid
-Lipitor
-Coumadin
-Nitrostat
-Zofran
-Percocet
-Narcan
-Aranesp -Dulcolax
-Magnesium Hydroxide
-Multivitamin Nursing Diagnosis Hemorrhage R/T pt Warfarin anti-coagulation therapy AMB inability of patient's blood to clot post surgical procedure. Nursing Interventions -The nurse will apply sandbags to the incision site for constant pressure to help stop the bleeding. -INR 3.43 (0.90-1.20) -PT 35.6 (11.8-14.8) -PTT 44.5 (22.7-36.7) -Pt has abnormal coagulation labs Nursing Diagnosis Impaired gas exchange R/T ventilation perfusion inequality secondary to COPD AMB pt SpO2 at 84% on Room air and exertional dyspnea (Ackley & Ladwig, 2011). Nursing Interventions -The nurse will monitor pt RR, depth, and ease of respirations, and signs of respiratory failure. -The nurse will auscultate lung sounds every 1-2 hours during shift. -The nurse will monitor the pt pulse ox every 1-2 hours during shift. -The nurse will apply cold compresses/ice packs and direct pressure to the site to help stop the bleeding -The nurse will apply SurgiSeal to the incision site per doctors order to try and seal the incision and stop the bleeding. -Because direct pressure will stop most external bleeding and is the most important first aid step. -Because ice acts as a vasoconstrictor to reduce bleeding at the site. -Because SurgiSeal heals wounds 3 times faster than sutures. and Rationales ("Adhezion biomedical: Surgiseal",2008.) -Because monitoring for theses signs & symptoms can help keep the patient from going into respiratory failure. -Because new or worsening wheezes and crackles may exacerbate COPD. -Because pulse ox readings are a sign of significant oxygenation problems. and Rationales Nursing Outcomes -Patient will maintain an O2 saturation of 90%-92% on 2L of O2 via nasal cannula by discharge. -Patient will use incentive spirometer at least 5 times per hour during shift. -Goal in progress. Patient had not been discharged at the end of my second day, but pt SpO2 was staying steady around 91%. -Goal partially met. Patient did use the incentive spirometer every hour, but was not able to do it 5 times every hour. -Patient will practice deep breathing when feeling anxious or short of breath during shift. _Goal Met. Patient did practice deep breathing when she was feeling anxious. Hemorrhage R/T patient Warfarin anti-coagulation therapy regimen AMB inability of patients blood to clot post surgical procedure. Nursing Outcomes -Patient incision site will be free of bleeding by discharge. -Goal in progress. Patient had not been discharged by the end of my second day. Patient was still actively bleeding at the end of my second day. -Patient will maintain head and neck position in order to help control and reduce the bleeding at the incision site during shift. -Goal met. Patient did maintain head and neck position during the shift. -Patient will keep the head of the bed at a minimum of 60 degrees to help reduce bleeding at the incision site during shift. -Goal met. Patient did keep the head of the bed at 60 degrees during the shift. Concept map By: Katie Przybysz Pertinent Patient Data Chief Complaint:
-SOB
-Abdominal pain Full Code
Tunneled dialysis catheter placement in right jugular vein
COPD exacerbation
Warfarin anti-coagulation therapy regimen.
Multiple hospital diagnosis
New dialysis pt. 71/Female D.C. and Evaluations and Evaluations Additional Nursing Diagnoses Delayed surgical recovery R/T pt normal coagulation therapy AMB pt continuous bleeding post-op 36+hrs (Ackley & Ladwig, 2011).
Impaired comfort R/T bleed secondary to surgical procedure AMB pt anxiety, irritability, and pt lack of situational control (Ackley & Ladwig, 2011). Noncompliance R/T knowledge deficit about the measures taken to stop the bleeding AMB Pt behavior indicative of failure to adhere to instructions that were given (Ackley & Ladwig, 2011). Anxiety R/T health status secondary to post surgical bleed AMB Pt verbal report of anxiety about the bleeding (Ackley & Ladwig, 2011).
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