Concept Map-Medsurg II Final (1) PDF

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Key Problem # 1 Ineffective Cerebral Tissue Perfusion    

Key Problem # 2 Impaired Physical Mobility  CVA  OT exercise: Pre/Strengthening B UE/LE daily  ROM exercises  Muscle weakness

CVA Neurocheck daily A&Ox2 ACS score 14/15

Reason for Seeking Healthcare / Med-Surg d/x: 53 y/o male admitted for CVA MCA Distribution Key Assessments: Vital signs, Neurological assessment, Morse Fall Scale, Skin integrity, Musculoskeletal strength, ROM exercises, Safety, Medications, Gag reflex Key Problem # 4 Risk for Falls

Key Problem # 3 Risk for Impaired Swallowing    

CVA Speech, Voice, Language Therapy Swallowing treatment Decreased gag reflex

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High fall risk score of 55 Muscle weakness HTN CVA HTN medications DM II

Problem # 1 Nursing Diagnosis: Ineffective cerebral tissue perfusion r/t CVA as evidenced by changes in motor/sensory functions and communication. Goal/Outcome: Patient will maintain stable vital signs and absence and ACS score of 14 or better. Nursing Interventions

Rationale

Patient Responses to Interventions

1. Assess and monitor vitals q 4 h.

1. To obtain baseline data and note any abnormalities.

2. Perform neurocheck daily q shift.

2. To obtain neurological status and compare with baseline and assess any trends or changes.

1. 0800: 154/90; 84 HR; 99% O2; 98.2F; 16 RR 0/10 pain 1200: 138/82; 85 HR; 100% O2; 98.7F; 17 RR 0/10 pain 1600: 147/80; 68 HR; 99% O2; 98.5F; 17 RR 0/10 pain 2. Eyes open spontaneously, confused, and obeys command. ACS score of 14/15. Pt not in distress.

3. Administer ordered medications, especially any anticoagulants, antiplatelet, and antihypertensive.

3. Medications can control and manage the pt’s health. Anticoagulants can improve cerebral blood flow. Antihypertensive controls blood pressure.

3. Lopressor 25mg, Plavix 81mg, Aspirin 81mg, Norvasc 10mg and other ordered medications given. Pt tolerated medications well and BP stable.

4. Position head of bed slightly elevated 30 degrees

4. Reduces arterial pressure by promoting venous drainage and may improve cerebral perfusion.

4. Patient states elevation feels comfortable.

5. Maintain complete bed rest.

5. Any activity or stimulation can increase intracranial pressure.

5. Patient understands he needs to stay in bed.

Patient/Family Teaching: 1. Review modifiable risk factors (hypertension, smoking, diet, physical activity) to help client make informed choices and commit to lifestyle changes. 2. Educate adverse effects of medications so patient/family can recognize and get help immediately. 3. Educate patient how to use call bell since he is on strict bed rest. Evaluation: Outcome met, patient’s vital signs were stable. ACS score of 14/15. Patient was left stable in bed with no distress or discomfort. References: Nursing Central from Unbound Medicine- Nurse’s Pocket Guide Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (12th ed., Vol. 1). Philadelphia: Lippincott Williams & Wilkins.

Problem # 2 Nursing Diagnosis: Impaired physical mobility r/t CVA as evidenced by decreased right muscle strength/control Goal/Outcome: Patient will perform active and passive range of motion exercises to maintain/improve muscle strength during my shift. Nursing Interventions

Rationale

Patient Responses to Interventions

1. Reposition q 2-4 h.

1. Repositioning patient can help reduce risk of getting pressure ulcers from staying in one position for a prolonged time.

1. Patient is able to reposition by himself every 2 hours.

2. Perform active or passive range of motion exercises 3x daily: 1100, 1500, 1900.

2. Range of motion exercises help joints maintain flexibility, improve strength, and prevent loss of motion.

2. Patient cooperative with active and passive ROM exercises to upper and lower extremities.

3. Observe skin integrity and use risk for decubitus ulcer assessment rating.

3. To determine the level of risk for pressure ulcers and assess status of skin.

3. Patient is dry and shows no indication of skin breakdown. Risk for ulcer score of 14.

4. Provide safety measures and determine fall risk using Morse Fall Scale.

4. To prevent any injuries or falls and determine level of fall risk.

4. Bed in lowest position, 2 side rails up, call bell within reach. High fall risk score of 55.

5. Assist and encourage participation with selfcare and ADLs.

5. To maintain hygiene and encouraging participation can enhance self-concept and sense of independence.

5. Patient able to do oral hygiene. Assisted with partial bed bath and perineal care. Pt tolerated we

Patient/Family Teaching: 1. Educate patient on how to use the call bell. 2. Review safety measures such as locking wheelchair before transfers, removal or securing of scatter/area rugs. 3. Teach active and passive range of motion exercises. Evaluation: Outcome met, patient performed active range of motion exercises within his own ability. References: Nursing Central from Unbound Medicine- Nurse’s Pocket Guide Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (12th ed., Vol. 1). Philadelphia: Lippincott Williams & Wilkins.

Problem # 3 Nursing Diagnosis: Risk for impaired swallowing r/t decreased gag reflex Goal/Outcome: Patient will pass food and fluid from mouth to stomach safely during my shift. Nursing Interventions

Rationale

Patient Responses to Interventions

1. Assess gag reflex.

1. To ascertain presence and strength of gag reflex.

1. Decreased gag reflex.

2. Note voice quality and speech.

2. Abnormal voice and speech patterns are signs of motor dysfunction of structures involved in oral and pharyngeal swallowing.

2. Dysarthria noted. Pt verbalizes “I have difficulty speaking.”

3. Assist with feeding and drinking.

3. To prevent and reduce risk of regurgitation aspiration of food and fluids.

3. Patient tolerated feeding well. No aspiration.

4. Elevate head of bed to high-fowler’s for 30 minutes during and after feeding.

4. To prevent and reduce risk of regurgitation aspiration of food and fluids.

4. Patient is cooperative.

5. Consult with speech language pathologist.

5. Collaboration with speech language pathologist to identify techniques to enhance client efforts and safety measures.

5. Speech, voice, language therapy once 4-5x/week and swallowing treatment once 2-3x/week. Pt tolerated well.

Patient/Family Teaching: 1. Educate patient to chew, eat, and drink slowly to prevent aspiration. 2. Recommend patient to avoid food intake within 3 hr of bedtime. 3. Encourage a rest period before meals to minimize fatigue. Evaluation: Outcome met, patient had no aspiration or complications with feeding and drinking. References: Nursing Central from Unbound Medicine- Nurse’s Pocket Guide Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2010). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (12th ed., Vol. 1). Philadelphia: Lippincott Williams & Wilkins....