Concept Map template- ATI Enteral tube feedings Practice challenge pt 3 PDF

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ATI TEMPLATE...

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Evaluation (Goals met/unmet)-15 pts LVN : Concept Map Enteral tube feeding Medical Treatment/Collaborative Care (Planning)-5 pts

Pt maintained strength and function of weakened left side, pt did not increase in strength, goal partially met.

Monitor medication regimen related to CVA; Aspirin 325g QD, Metoprolol 100mg QD, Atorvastatin 80mg QD, Tylenol 650mg PRN Q4-6hr.

Pt maintain aspiration precautions during hospital admission and was free of feeding complications and aspirations. Met goal.

Assess/monitor pain level by using face scale and manage with PRN analgesic.

Pt maintained adequate peripheral tissue perfusion. Cap refills and MAP WNL. Goal met

Monitor NG tube placement, test pH prior to NG feeds, administer feeds/meds and flushes as ordered by MD.

Patient will maintain or increase strength and function of affected or compensatory body parts by discharge. / Nurse will perform PROM/ROM and refer pt to PT/OT/ST.

HR: 97, RR 21 Pain level 5/10 on face scale Headaches Trouble swallowing

Hypertension Hyperlipidemia

Goals/Nursing Interventions (Planning)-25 pts

Patient will demonstrate and verbalize understanding of feeding methods appropriate to his situation while preventing aspiration upon discharge. / Nurse will educate pt on aspiration precautions, dietary needs, positioning during and after feeding, and refer pt to Nutritionist/Dietician. Nurse will test pH prior to feeds.

B/P: 152/89

Medical History (Assessment)-5 pts

Monitor and maintain aspiration precautions at all times.

Patient will not experience any further deterioration or reoccurrence of deficits during admission stay. / Nurse will monitor V/S, neuro status and peripheral pulses.

Signs/Symptoms (Assessment)-10 pts

CVA

Coronary Artery disease

Concept

History of CVA (2 wks ago- 3/08/21)

Perfusion

Impaired swallowing Compromised of left sided function Risk for aspiration complications

Diagnostic Studies (labs, XR, etc.) (Assessment)-5 pts Interrelated Concepts (Analysis)-5 pts

CT Scan

Nursing Diagnosis (Analysis)-30 pts

Immobility RT to left sided weakness

CT Angiography/Arteriography

Ineffective cerebral tissue perfusion related to interruption of blood flow as evidence by changes in motor/sensory responses.

Clotting RT CVA hx and need for blood thinners

MRI

Impaired swallowing related to CVA hx as evidence by choking when drinking PO fluids. Impaired physical mobility related to CVA hx as evidence by left sided weakness.

ECHO: mild aortic stenosis Ineffective airway clearance RT CVA hx Neuro/Physical Exam Impaired swallowing RT CVA hx and need for enteral feedings Risk for falls RT CVA and Left sided weakness

Swallow study LDL 182, HDL 37, Lipid serum 213- Abnormally high...