Concept Map

high class. My name is Karina Lopez.

And my concept map is based on an infected two cubits ulcer found in my first patient.

First we're going to look at the path of physiology of the disease process.

Then we're going to look at the nursing process

then

the royal adoption model and lastly cussin.

So let's start with pastel o physiology and the disease process.

Prolonged external pressure applied to tissues and combination with sheer

or excessive moisture can cause non blanching or redness on intact skin.

And it could also lead to

skin breakdown. So damage to the dermis, epidermis

or things could get worse where there will be complete skin loss

the

and you'll be able to see muscle bone or sub Q.

When that happens and you lose the skins.

Outer layer,

bacteria could be brought into the body

and it causes infection.

So for my patient and the medications related to the disease process,

he was taken Xhosa

which is a broad spectrum antibiotic, meaning that

it helps

with a lot of different kinds of bacterias.

And my patients affected ulcer needs this antibiotic to fight

off or kill the bacteria that entered his body.

I decided to include insulin, also

an anti diabetic drug to lower blood glucose because

In my patient's case he's a Type two diabetic

and he needs to control his blood sugar in order for his wound to heal

and

then we'll go to his lab values and again

blood glucose was important.

The normal was 71 - 110. And his lab value for blood glucose was 167 which was high.

And again, it could

mismanagement of his diabetes would delay wound healing.

So it's important that he manages his glucose

in order to get better

and his hematocrit

Was also low and this indicates infection or prolonged illness.

The normal was 40-54 and his was 27.3, so it was significantly low.

And for the lymphocyte absolute count and the normal was 2 - 3.4.

My patient

Slot value was .9,

which was low. And this also indicates infection

and his lactic acid arterial.

That value

was on the high side at 6.3 when the normal is 0.5

22.

And again this indicates infection, sepsis or dehydration.

And this is important to monitor because we

don't want we don't want him going septic.

And the diagnostic

test,

This patient had a Braden scale score of 13. So he was

um uh

moderate risk for

developing more pressure

injuries.

And he also did his cbc labs

the glucose monitoring a physical assessment had to tell.

And I also decided to include a bacterial culture diagnostic test. Because

let's say the zoo said he was taking didn't work.

They could run a bacterial culture test to identify

the correct antibiotic for his specific bacterial infection.

And now we're going to look at the nursing process

and we start with the head to toe assessment,

the musculoskeletal system,

the integrity to elementary system and the cardiovascular

system where the main areas I focused on.

Even though I did a full head to toe assessment on him because

these were the areas that impacted his

his sacred

his ulcer infection,

right

musculoskeletal.

He had upper and lower extremity weakness, especially lower extremity weakness.

So he had difficulty ambulance waiting or even moving,

especially since they had him on pretty strong medications

including

I think it was an antidepressant

and his skin was crackly

dry, especially on his lower extremities. He had a stage to ulcer on his sacrum

and the temperature of his skin was just cold

again

on his lower extremities and upper extremities.

So this showed poor profusion and poor skin integrity.

The parador vascular

He had lower extremity pitting edema plus two

and he had

venous insufficiency and poor circulation.

And for the three problems. Let's start with the first one.

The first problem I identified with my patient was his impaired skin integrity.

So my plan and golf for it was

that the patient sacred ulster injury would not

progress into stage three during my shift.

The interventions I would take for this

were to monitor

the pressure ulcer

make sure the dressing is clean and intact

to prevent more bacteria from entering his

his injury

and to reposition him. So he doesn't get

other

pressure injuries on other sites.

And

my plans and goals were met successfully

for the second problem found in my patients

was the inability to ambulance.

And I didn't want him falling. So that was my

plants

slash school

for my shift

that the patient will not fall during my shift.

And the interventions

I did

to prevent him from following

where to put up the patient's side rose after I lowered them,

I instructed the patient to use the call light to ask for assistance

and I kept his things within reach so he wasn't tempted

to climb out of bed and ultimately end up getting hurt.

And my

evaluation for this, I would say I met

my plans and goals successfully.

And lastly, the third problem that I identified with my patient was

that he was a type two diabetic.

So my plan

for him was

two.

Not

well my goal was that he wouldn't go into hippo to hypoglycemic or

hyperglycemia mixed state

during my shift.

And then preventions I would do I did to prevent this

Where to monitor the patient's blood glucose,

administer insulin as needed and monitor his carbon take.

So

what he got to eat.

And my again my plans and goals were met successfully.

Next, we'll look at the Roy adaptation model.

This includes

the

physiologic cycle,

psychologic mobs,

no physiological mode.

Self concept mode. Role function mode and interdependence mode.

And for all of these I used the focal stimuli.

So

physiologic mode and I brought the patient water when he was thirsty

for self concept. I provided privacy for my patient when I assessed him

and

for the role function mode. I helped the Cnh.

Change and clean my patient because he wanted to look presentable

to his visitor

for interdependence mode.

His he had

he was complaining of the high tv volume and it was upsetting him

so I lowered it for him and told him to press the collide

if he needed anything.

And lastly

well look at cousin

the Houston competencies which includes patient

centered care safety teamwork and collaboration.

Evidence based

practice, quality improvement and informatics.

Then we'll look at the examples of each

for patient centered care.

The patient was provided with the bed bath

that he requested

for safety. The patient's side rails were kept up to prevent him from falling

teamwork and collaboration.

I helped my nurse change the patient's soiled wound dressing

and evidence based practice when emptying the patient's forward catheter bag.

I made sure the draining tube did not touch

anything to prevent any bacteria from entering the bag.

And I actually didn't really think about it. It was my nurse that

basically told me that

it was evidence based that they they don't allow the little to being

to touch anything because they don't want to introduce more bacteria into the bag

and quality improvement.

My nurse informed the patient significant other about the importance

of managing blood sugar so that the patients home care

provides better outcomes for him in the future.

And lastly for informatics. The Nerds used the M. R. two.

Um

to look at the patients

to do her last check on the patient's medication.

So

yeah, this was my presentation.

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