Concept Map week2 PDF

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Concept map...

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Step 1: Based on the clinical data collected, develop a skeleton diagram of the clients health problems. Write the major medical diagnosis in the middle of a blank sheet of paper, then add associated concepts flowing outward from the medical diagnosis. The medical diagnosis is the primary health problem, the concepts are those that are the actual responses to the health problem supported by assessment data. Develop the skeleton diagram.

#1 Infection

#2 Perfusion

#3 Gas Exchange Patient information ◦

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83 yr old male admitted on 6 Sept for consultation w/ infectious disease for recommendations regarding perioperative antibiotic regimen and CT surgery. Hx of CKD, COPD, AFib, DM, HTN, HF, ICD Peripheral IV R hand saline locked, Peripheral IV R forearm saline locked, CVC R internal Jugular Cardiac 2g diet High fall risk Puncture site neck R temporary pace site, Puncture site R & L groin anterior, Incision L chest pacemaker pocket (with possible infection & hematoma) Alert & oriented x4 RA and 1 L NC at night when sleeping

Step 2: Analyze and categorize the data gathered from the medical records and the brief encounter with the patient. Identify and group priority assessments, treatments, medications, and medical history related to the concepts and medical diagnosis. All medications, pertinent lab values, diagnostic tests, etc. should be incorporated into your diagram. If you have difficulty understanding how a symptom, laboratory value, treatment, drug, etc. is categorized, please put it off to the side of the map for further discussion with your clinical or staff instructor. If the data under each concept is something you are looking at and relates to the concept but is not abnormal, place an Asterix or star next to it. That way we know that you are looking at the data and that it relates to the concept but it may not be abnormal.

Brief Patient information #2 Perfusion

#1: Infection ◦

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Blood Cultures taken 9/8 & 9/9 o Results of 9/8 blood cultures showed no growth o While waiting on results of 9/9 blood culture pt is on Vancomycin 166.7 ml/hr Hx of cellulitis with persistent staph epidermis bacteremia o Pt has been on long term antibiotics therapy with no results on preventing recurring staph infections Pt had complete heart block s/p CIED recently complicated with RV lead infection and recurrent bacteremia due to staph epidermis o Lead extraction on 9/8 and now has temporary transvenous pacing Abnormal Lab levels o WBC – 17.7 (H) CT chest thorax w/ contrast on 9/7 o Indicated small hiatal hernia with exophytic nodule arising inferiorly from L thyroid gland

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Wounds:

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Puncture site neck R temporary pace site o Puncture site R & L groin anterior o Incision L chest pacemaker pocket (with possible infection & hematoma) Poor oral care o

Step 3: Next, use a different color pen to draw or arrows in word to make a line between concepts and how they are inter-related. Be prepared to discuss with your clinical or staff instructor. Step 4: Identify nursing interventions related to each concept, be sure to include patient teaching.

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83 yr old male admitted Sept for consultation w/ ◦ Hxonof6Afib infectious disease for recommendations regarding o Has temporary transveous pacing ICD perioperative antibiotic regimen andCT surgery. Settings at VV1 (76, 5,1) Hx of CKD, COPD, AFib, DM, HTN, HF,ICDHR paced at 75 Peripheral IV R hand locked, Peripheral IV R forearm ◦ saline Q4 CMS checks saline locked, CVC ◦R internal Jugular Q2 turner Cardiac 2g diet ◦ Vitals – High fall risk o BP – 101/58, 95/50, 105/59 Puncture site neck R temporary pace site,95, Puncture site R o O2 – 98, 94 & L groin anterior, Incision Lochest pocket (with RRpacemaker - 20 possible infection & ◦ hematoma) Hx of HTN, BP 100s Systolic, MAP 70-80s Alert & oriented x4◦ EF – 30-35% RA and 1 L NC at night sleeping ◦ when Cap refill >2 secs w/ weak pedal and radial pulse ◦

#3 Gas Exchange      

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R & L upper and lower lobes diminished breath sounds Continuous pulse ox with oxygen sats in the 90s throughout the day* Pale skin, cool to tough Cap refill >2 seconds RA with 1L of O2 at night when sleeping Resp rate 20 throughout the day o Increased WOB when ambulating o Needed 4L of O2 to regain 90% O2 Hx of COPD, former smoker Abnormal lab values o CO2– 17(L) o Hemoglobin 11.6(L) o Hematocrit38.3(L) Use ofspirometer 10xevery 2hours HOB to stay at 30 degrees or more Meds: o Budesonide-formoterol 2 puffs daily o Albuterol HFA 2 puffs PRN

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Obesity, edema generalized w/ lower and upper extremities 1+, and scrotal edema 2+ DM controlled * Continuous Pulse Ox Hx of Heart Failure, CKD, HTN, Afib Daily Weight Cardiac Diet 2g Generalized bruising and ecchymosis - Braden score 18

Incision L chest pacemaker pocket (with possible infection & hematoma) IV R forearm infiltrated/developed hematoma later into shif o IV removed on 9/9 BUN 21 (H), Creat 1.68 (H), GFR 39 (L) I & O total 960 ml  +60 Sepsis – low risk* Meds: o Spironolactone 25 mg o Pravastatin 40 mg o Losarten 25 mg o Furosemide 40 mg IV o Ferrous Sulfate EC tab – 325 mg Hx of numbness and tingling in R & L pinky fingers

Step 5: Evaluate the actual patient response to each nursing intervention, not the expected outcome. Carry the concept map with you throughout your clinical day and update accordingly each day care is provided. #4 specific/detailed nursing Interventions

#5 Patient response to the NI and evaluation of the NI & concept. For example: the NI was to assess pain level scale 1-10 every 2 hours. The response was: patient stated pain was a level 5 (comfort level was a 4), described pain as stabbing in right incision, evaluation patient was able to describe pain. Another example: administered 650mg of Tylenol at 1500 for pain of 5. The patient response/evaluation: patient took Tylenol and pain was decreased to number 3 within one hour.

#1 Infection 1. Administer Antibiotic Medication of Vancomycin 166.7 mL/hr

2. Provide Wound Care for puncture site at the neck R side temporary pace site, puncture site R & L groin anterior, incision L chest pacemaker pocket (with possible infection & hematoma)

3. Provide daily cares of bath and oral care

Pt was given antibiotic medication at 1730, IV infiltrated and developed a hematoma. o Attending was paged and recommended to monitor site and remove IV line. ◦ IV was removed and Vancomycin 166.7 ml/hr was continued in the R hand IV site with no further complications. ◦ Medication was administered to help aid in the prevention of any further infections and to help the pt get rid of the current ICD infection. ◦ Pt tolerated the medication in R hand IV line fine. ◦ Wound care was provided as prescribed by wound care provider to decrease the risk of any further infections. ◦ The puncture site at the R neck side with the temporary pacemaker was monitored and no dressing change was done. Dressing clean, dry,intact with small amount of bloody drainage. ◦ R & L anterior groin puncture site dressing was removed and replaced with gauze and clear adhesive dressing on both sites due to small amount of bloody drainage. ◦ The L chest incision of previous pacemaker was monitored for any further signs of infection such as redness, warmth, drainage, etc. The incision dressing was not changed and there was scant amount of drainage, warmth was noted in chart, and hematoma was sof surrounding the incision site/dressing. ◦ Pt tolerated the dressing site changes fine. Pt was given a bed bath with CHG during my shif and was offered oral cares but denied the oral cares till before bedtime. The bed bath with CHG helps to reduce the spread of infection in the hospital and good oral hygiene will also help in reducing bacteria in

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4. Practice good quality hand hygiene throughout the shif

5. Monitor the following labs for any abnormals: ◦ WBC ◦ Blood culture

the mouth and without good oral hygiene the pt will be at risk for oral infections such as tooth decay and gum disease. ◦ Regular handwashing is one of the best ways to remove germs, avoid getting sick, and prevent the spread of germs to others. ◦ Proper hand hygiene was followed by nursing staff by ensuring hand sanitizer was used before and afer touching the pt. ◦ Pt was educated on proper hand hygiene and why it is important to ensure not only staff practices proper hand hygiene but he does as well. o Follow these five steps every time.  Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.  Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.  Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.  Rinse your hands well under clean, running water.  Dry your hands using a clean towel or air dry them. ◦ Pt interpreted the education well and practiced good hand hygiene before and afer meals and anytime he used the bathroom. ◦

The following labs were monitored for any abnormal levels that would indicate signs of infection: ◦ WBC level was 17.7 (H) ◦ The high level of WBC is due to the pt having an infection with his ICD RV lead, as well as having recurrent bacteremia due to staph epidermis ◦

Pt was placed on Vancomyocin 166.7 ml/hr antibiotic to help fight off this infection and reduce any further infections from arising. ◦ Pt tolerated the R hand IV medication well. ◦ Pt was placed on a 2g cardiac diet and tolerated the diet well. o He consumed all of his breakfast and lunch in compliance with his cardiac 2g diet. ◦ With proper nutrition it can aid in ensuring a person has a strong ◦

6. Ensure pt receives adequate nutrition

Blood Cultures taken 9/8 & 9/9 ◦ Results of 9/8 blood cultures showed no growth ◦ While waiting on results of 9/9 blood culture pt is on Vancomycin 166.7 ml/hr

immune system, which can offer protection from seasonal illness and other health problems.

Evaluation: ◦

Overall my pt was very pleasant and cooperative in the care he received. He was receptive to the hand washing education and this was seen by witnessing the pt practice proper hand hygiene before and afer meals and afer going to the bathroom. Although he was not able to physically wash his hands with soap and water due to being a high fall risk and having an unsteady gait. He was provided with hand sanitizer to ensure his hands stayed cleaned throughout the day. His goal for the day was to feel better and by providing the antibiotic medication, being able to ambulate the hallway, and receive daily cares such as a bath, the pt stated that the care provided along with the medication helped him to feel better. He did state his sleep was poor and that was due to having so many people in and out of his room. Thus unless needed I ensured that anyone entering his room was minimal and that he was able to get at least 3 30 min naps in uninterrupted throughout my shif. Overall I believe the care provided to my pt was met in accordance with ensuring that his risk of further infection was reduced and ensured the pts oxygen levels were met throughout the shif....