Concept Map Template 4 20 PDF

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Summary

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CONCEPT MAP

RASMUSSEN COLLEGE

Disease- COVID-19

Body System / Pathophysiology- The immune system is getting attacked because the corona virus made its way into his respiratory tract. It then infected him causing him to have a lot of respiratory problems such as a productive cough and shortness of breath.

Assessment FindingsSigns & Symptoms- Sore throat, (What should I see? Objective vs. diarrhea, fever, SOB, cough, warm Subjective findings) skin, dry mucous membranes, BP Patient actually looked sick he was 156/60 HR 110, Temp 103.1 orally, pale and sweaty. You can see he is O2 sat 92-93% he is on 2 L nasal having trouble breathing. He is also canula, RR 24-32, and pain is a 4/10 having a productive cough. His mucous membranes are also dry He is complaining of a sore throat, fever, diarrhea, soft non tender abdomen with a hyperactive bowel sound. Skin is warm to touch. Fever Diagnostic Procedures / Labs- (Why was it done? What are the results? Normal vs. Abnormal?) He got a chest X-ray done and it showed opacities which is consistent with Covid-19. A 20 g angiocath was inserted into his L forearm to be able to administer medications. A CBC was done and it showed a WBC of 3.1 which is low and a differential was done and showed lymphosites and neutrophils are low meaning there is a viral illness. Platelets were 162 the serum lactate was elevated 2.1. He also tested positive Influenza A and negative for influenza B. Coronavirus results are still pending. Sodium was a little low at 132 and chloride low at 93. CO2 was at 17 with a potassium at 3.1 BUN was elevated at 38. Creatinine was elevated at 28 and GFR was low at 78. His calcium was within normal limits and ALT elevated at 68 AST 50 elevate coags with a PT at 19 and an INR at 1.1 APPt came back at 28 CRP was elevated at 18. There was a 12 lead EKG done and that showed sinus tachycardia

CONCEPT MAP

Treatment / Meds- 1 gram of Tylenol was given 15 minutes ago for the fever. He also received an hour long DuoNeb with albuterol in it in the ER. Xopenex neb with methylprednisolone 125 IV push and also received 1 L IV bolus.

RASMUSSEN COLLEGE

Reason for Treatment / Meds(Why is this patient taking this med? Why was this med added to the treatment plan?) The Tylenol is to help with the fever. The 2 nebulizers are to help with his shortness of breath. The methylprednisolone is to help with all the inflammation in his lungs. The IV bolus is to help with the diarrhea that he is having causing him to be dehydrated.

CONCEPT MAP

Nursing Considerations- Know that this patient is in airborne and contact precautions until the r/o of COVID-19 comes back.

RASMUSSEN COLLEGE

Nursing Diagnosis(es) Impaired breathing patterns related to shortness of breath. Anxiety related to unknown etiology of the disease Infection related to failure to avoid pathogens or exposure to COVID-19

Patient Education / Dietary Considerations / Follow-up- We want to make sure that this patient knows that he is contagious so to not go by anyone. Do not go out in the public. He needs to stay quarantined for at least 14 days. We want to encourage the patient to drink a lot of water to decrease likelihood of dehydration. We also want to enough patient to consume food items high in vitamin C if possible, to help out his immune system. There should be a follow up testing done to see if he see has the COVID-19 virus.

CONCEPT MAP

Brand Name & Generic Name Pharmacologic Class

Therapeutic Class

Mechanism of Action

RASMUSSEN COLLEGE

Tylenol-acetaminophen Xopenex- levalbuterol Methylprednisolone- Depo-Medrol Nonopioid analgesics Adrenergic corticosteroid Antipyretic Bronchodilator Antiasthmatics, corticosteroids I nhi bi t ss ynt he s i sofpr os t a g l a ndi n st ha tma ys e r vea sme di a t or sofpa i na ndf e ve r , pr i ma r i l yi n t heCNS. Ha snos i g ni fic a nta nt i i n fla mma t or ypr o pe r t i e sorGIt o xi c i t y . Re l a xa t i o nofa i r wa ys moot hmus c l ewi t hs ubs e q ue ntbr o nc ho di l a t i on. Re l a t i ve l ys e l e c t i v ef or be t a 2( p ul mona r y )r e c e pt o r s . Supp r e s s i o nofi nfla mma t i ona ndmodi fic a t i onoft henor ma li mmu ner e s pons e . Re pl a c e me nt t he r a pyi na dr e na li n s uffic i e nc y .

Reason Given-

This patient is getting Tylenol because he has a fever

Why is this relevant to this patient?

This is given because the patient has a lot of swelling going on in his respiratory tract.

Pre-Administration Assessment(s)

This is given because the patient was having shortness of breath Get an accurate temperature reading We will want to listen to his lungs and assess vital signs

Post-Administration Assessment(s)

Assess respiratory function as well as vital signs Check the temperature after giving the medication 30 minutes after Assess vital signs and listen to lungs again

Nursing Considerations

We wll want to assess the patient’s respiratory function especially the O2 % as well as vital signs. Assess overall health status and alcohol usage before giving the medication. Assess for rash periodically. Assess fever; note presence of associated signs. Use caution in patients with cardiovascular disorders, history of seizures, hypokalemia, hyperthyroidism, DM. We will assess for signs of adrenal insufficiency before and periodically during therapy. We will also want to assess for changes in level of consciousness and headache during therapy

CONCEPT MAP

Drug-Specific Nutritional Education

RASMUSSEN COLLEGE

Avoids products containing alcohol, aspartame, saccharin, sugar, or tartrazine Nothing in regard to nutrition needs to be avoided

Drug-Specific Patient Education

Grapefruit Juice Take exactly as directed, avoid alcohol while taking medication, discontinue and notify physician if rash occurs, consult health care professional if fever does not go away. Take medication as directed, use this medication first if using other inhalation medications and allow 5 minutes to elapse before administering other inhalants. He should also rinse his mouth frequently. Instruct patient on correct technique of medication administration. Avoid consumption of grapefruit juice during therapy....