Nursing Concept Map Medsurg 2 PDF

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Concept Map Student Name: Astrid Hernandez Instructor: Prof. Dominguez

Erickson’s Developmental Stage Related to pt. & Cite References (1) Stage 6: Intimacy Vs. Isolation. The most important events in this stage of life are intimate relationships. In this stage of life , young adults need to form intimate, loving, relationships with other people. Success leads to strong relationships , while failure results in loneliness and isolation ( Lewis & Orenstein, 2020).

Patient Education (In Pt.) & Discharge Planning (home needs) Teach patient proper handwashing and aseptic wound care that can be done at home for infection prevention. Discuss and educate patient on proper diet to prevent any future constipation or complications. Educate patient on a high fiber diet to prevent any future constipation. Explain to patient that if constipation persists, to notify provider. Instruct patient that they must come back for follow up visit to ensure proper wound healing is taking place. Educate patient to monitor high temperatures and abnormal changes in wound. If any of the two occur, notify the provider.

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Patient is of American and Hispanic descent. The patient identifies self as American. The patient is currently a

Chief Complaint

Patient Information Diagnostic Test/ Lab Results with dates and Normal Ranges (3)

Test WBC

CRP

Norms

Date

5.010.0x 10 ^3/mm ^3 0.3 to 10 mg/L

02/11/2 021

Urinalysis Leukocyte esterase

Negati ve

Urine Culture CT Scan

Negati ve Clear

Current Value 15,000 x 10^3/m m^3

02/11/2 021

17.4 mmol/L

02/11/2 021

Negativ e

02/11/2 021 02/11/2 021

Negativ e Positive for obstructi on in appendi x.

(National Institute of Diabetes and digestive and Kidney Diseases, 2020)

(1) Name: EV Age:24 Gender: Male Code Status: No Stratified DPOA: Living Will: Not specified

Patient complains of RLQ pain lasting for about the past two days. Patient is also complaining of SOB, nausea and vomiting.

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1). E.V. is a 24-year-old male patient who presented to the ER with severe RQL abdominal pain. Patient states he was at work lifting heavy equipment when he suddenly felt excruciating pain in the abdomen. Patient states that when he arrived at home, he took Advil (ibuprophen) 400mg every 6 hours to help alleviate the pain. Initially, the Advil helped alleviate the pain but eventually the pain persisted and became unbearable. Patient states that the pain gradually got worse and the patient began experiencing nausea and vomiting about 3 times in the past 24 hours. Patient will be going under appendectomy surgery to remove the appendix an prevent possible sepsis. Patient states being worried about upcoming surgery. Acute appendicitis is the inflammation and obstruction of the appendix. Fecal mass or thick mucus can obstruct the narrow passage of the appendix which blocks the mucus outflow. The obstruction causes increased pressure, distension, and accumulation of bacteria that can lead to perforation of the appendix. Appendicitis is dangerous as feces can leak out of perforated appendix and get absorbed in the bloodstream causing systemic infection or sepsis (John Hopkins University , 2021). Medical History Patient has a medical history of ECZEMA. The patient was diagnosed in 2012. Patient has a history of ADHD and was diagnosed 2009. The patient also has a history of PAC related to the intake of Adderall XR prescribed by Psychiatrist. The PAC is controlled and asymptomatic. The patient has a history of a broken wrist from a basketball game in high school in 2013 for which the patient had to wear a cast. Surgical History ORIF 2013

Admitting Diagnosis Acute Appendicitis

Social History

Medical Management/ Orders/ Medications & Allergies (2) Name

Dose

RT

Freq.

MOA

Zosyn

3.3 g

IV

6hrs

Prevent destruction of piperacillin

Ultram

50 mg

IV

RN Considerations

Monitor for fever , abdominal pain, diarrhea, pus, mucous in stool. 12 Analgesic Watch for hrs. seizures , excessive sedation, or somnolence (Davis’s Drug Guide, 2020)

Onset/Peak/ Duration (Insulin) Immediate/ immediate.

Immediate/ 12 hours

Patient is currently single. The patient recently got his first apartment and lives on his own with his dog. The patient is a recent graduate and works as a Marketing executive. The patient states being excited about this new journey in life after graduating college. The patient has no history of drug/substance use. No history of tobacco use. The patient states occasionally drinking socially with his friends. Patient states having good relationship with his family and friends.

Priority nursing diagnosis #1 Acute Pain related to presence of surgical incision as evidenced by autonomic responses

Vital Signs (4) Temp: 101.2F BP:130/86 P:100 RR:20 HT/WT: 6’3” 195 lbs.

Nutrition/Hydration (8) Patient states losing appetite , patient has been NPO before and after appendectomy.

Neurological (5) Patient is A&O X 4 Cooperative. PERLLA within normal limits. Cranial nerves all intact within normal limits.

GI (9) Abdominal pain in RQL, soft and tender when palpated,

Cardiovascular (6) S1 and S2 regular apical, capillary refill < 3, 2+ quality bilateral radial pulse, 1 + quality bilateral lower extremities, no edema.

GU (10) Non distended, continent, clear yellow urine, no odor.

Outcome/Goal #1 Report pain is relieved or controlled

Interventions #1 Administer analgesics as indicated. Relief of pain facilitates cooperation with other therapeutic interventions.

Integumentary (12) Skin appear5ed diaphoretic upon admission to hospital. Wound site is currently dry and intact, IV site is patent clean and dry without signs of infection or infiltration.

Endocrine (13) Endocrine system within normal limits. No hormone or steroids use.

PC Outcomes/Goal

Risk for infection related to postoperative surgical incisions

Patient’s wound will be free of infection through hospital stay until discharge

Priority nursing diagnosis #2 Risk for infection

Rest/ Exercise (11) Pt states living an active and healthy lifestyle. Patient states typically sleeping 6-7 hours a day . Pt is currently on bedrest due to surgery and ambulates with

Outcome/Goal #2 Achieve timely wound healing , free of signs of infections/inflammation.

Misc. (Ht/Wt) ROM within normal limits bilateral in upper and lower extremities. Interventions # 2 Practice and instruct in good handwashing and aseptic wound care. Encourage and provide perineal care.

Assessment/ Evaluation #1 Patient reports pain level decreasing from an 8 to a 2 in a scale of 1-10. The patient appears relaxed and states not feeling any discomfort.

Potential Complications/ at risk for

Psychosocial (14) Stressed due to recent appendicitis , anxious due to pain, cooperative.

Respiratory (7) SaO2 is t 95% on room air. No adventitious sounds in lungs bilaterally, no cough.

   

Assessment/ Evaluation #2 Patient has practiced proper hand washing. The patient has also been provided with perineal care and wound care. The wound is showing normal healing process. No signs of infection, inflammation, purulent drainage , erythema, or fever.

PC Interventions Monitor vital signs Assess for pain Assess wound for any abnormal changes Assess patients’ labs, particularly WBC

PC Evaluation Plan Goal was met. Patient was compliant and was able to follow proper handwashing and aseptic wound care. Patient was compliant with medication . wound was kept free of infection during hospital admission....