Concept Map 4j5e1t
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- Pages: 9
NSU Nursing Dept.
1
Adult Nursing Courses
Report Worksheet Student’s Name: __Sinai Martinez_______________ Date___2/14/2013_ Client Initials ___R. M_____Room _____527___ Date of ission ___2/18/2013______ Age __65___ Gender: M_X_ F___ Religious Preference_Catholic______ Ethnicity______Hispanic____ Medical Dx _______Angina_____ Diet ____NA restriction________Weight __205_____ Activity ____Regular___Allergies _NKA___ Primary RN _____Julia_RN____ THURSDAY
FRIDAY
Time
Tem p
Puls e
Repor t 0800 1200
97.9
70
98.6 98.8
66 69
Respiratio ns
Report from RN
Things to Do
18
Blood Pressur e 130/90
Pain Ratin g 3
17 17
128/80 126/80
3 0
Time
Tem p
Puls e
Respiratio ns 15
Blood Pressur e 143/87
Pain Ratin g 0
Repor t 0800 1200
98.0
77
98.8 98.6
80 78
17 16
138/86 129/80
0 0
Report from RN
Things to Do
NSU Nursing Dept.
2
Adult Nursing Courses
MEDICAL/SURGICAL HISTORY Medical Diagnosis (Reason for seeking health care): _____Angina____
Medical History
Correlation to Medical Dx/Reason for seeking health care
Chest pain
Chest pain is a symptom of angina caused when the coronary arteries aren’t getting enough oxygen.
Hypertension
High blood pressure can be a result of the vessels being blocked or constricting.
Surgical History
Correlation to Medical Dx/Reason for seeking health care
N/A
PATHOPHYSIOLOGY Medical Diagnosis (Reason for seeking healthcare): __Angina__ Textbook description of pathophysiology and clinical manifestations relating to client’s primary disorder Angina pectoris is a clinical syndrome usually characterized by episodes of pain in the anterior chest. The cause is insufficient coronary blood flow. Resulting in decreased oxygen supply when there is an increase myocardial demand in response to physical exertion or emotional stress.
Reference: Smeltzer, C. S., Bare, G. B., Hinkle, L. J., Cheever, H. K. (2008) Brunner & Suddarth’ Textbook of Medical-Surgical Nursing. Philedelphia, PA: Lippincott Williams & Wilkins.
Comparison with client data (subjective & objective) Subjective: Patient proclaims pain on exertion, when exposed to cold, when eating heavy meals, and when stressed. Pain radiates to jaw. Objective: SOB, pallor, nausea and vomiting,
NSU Nursing Dept.
Date
3
Adult Nursing Courses
Lab Study
Current La b Val ues
Normal Values
Previous/ ission Data
Significance of abnormal values
2/14/13
SIGNIFICANT LABORATORY DATA DIAGNOSTIC TESTING Test (Include the Date) ECG (2/12/13)
Nursing Interventions (Pre & post procedure nursing care) Educate the patient on the procedure. Let them know that it will be non invasive. Leads will be placed on the chest and electrical impulses will monitor the hearts condition.
Results & Nursing Implications Shows T-wave inversion which can be attributed to changes indicative of ischemia.
NSU Nursing Dept.
4
Adult Nursing Courses
Routine IV fluids Type of Fluid (Identify as Hypo/Hyper/Isotonic)
Rate
Location of IV Site
Assessment of IV Site
N/A
MEDICATIONS (List all Routine Medications currently ordered for the client) Generic/Trade Name
Dosage
Route
Frequency (times to be istered)
Nitroglycerine/ Nitrates
Patch
Therapeutic Drug Classification
TID
Nursing Process Assessment & Interventions
Nitrate
MEDICATIONS (List all PRN Medications currently ordered for the client) Generic/Trade Name
Dosage
Route
Frequency
Therapeutic Drug Classification
Nursing Process Assessment & Interventions
NSU Nursing Dept.
Thursday’s Assessment Sheet Cardiovascular Apical Pulse: Regular Irregular
Neurological Oriented: Date Time Disoriented Unresponsive
5
Adult Nursing Courses
Awake
Alert
Lethargic
Speech: Clear Garbled Slurred Appropriate Aphasic Inappropriate ROM: Full Limited: Complete Below Facial Droop: Right Left None Left Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Numbness or tingling Right Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Left Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Right Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Grasp R: Normal Weak Absent Grasp L: Normal Weak Absent Pupils R: ___mm Sluggish Brisk Fixed Pupils L: ___mm Sluggish Brisk Fixed
Peripheral Pulse: Present Upper Lower Edema Location: Basic Rhythm:
Gastrointestinal Abd: Soft Non Tender Tender Bowel Sounds X4 Hyper Hypo Absent Stool/Appearance:_______ Ostomy:______ NGT cont intermittent clamped Incontinence
Respiratory Even
Unlabored
Uneven
Labored SOB SOB with exertion Lungs: Clear Bilateral
Cough:
Productive Nonproductive Sputum: Color ________ Amount:_____________ Consistency:__________ Suction:______________ O2: NC____Liters Mask Vent Trach Psychological
Anxious Depressed
Cooperative
Urine: Clear Incontinence
Cloudy
Musculoskeletal
Abnormal Lung Sounds
Calm
Genitourinary
Gait: Steady With Assist Unsteady Device: Crutches Walker Cane Traction Type:_______ Ck:q______hours CMS checks every_____ hrs within normal Integumentary
Restless
Combative
Sensory Visual impairment: Yes No Auditory impairment: Yes No
Warm Cool Diaphoretic Color______ Preventative Measures Breakdown Special Skin Care:________________
NSU Nursing Dept.
Adult Nursing Courses
If yes, describe:
Surgical Site Location:________ Dsg Clean & Dry Changed Incision: Approximated no s/s infection Redness Drainage
6
NSU Nursing Dept.
Neurological Oriented: Date Time Place Disoriented Awake Unresponsive
7
Adult Nursing Courses
Friday’s Assessment Sheet Cardiovascular Apical Pulse: Regular Irregular Alert
Lethargic
Speech: Clear Garbled Slurred Appropriate Aphasic Inappropriate ROM: Full Limited: Complete Below Facial Droop: Right Left None Left Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Right Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Left Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Right Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Grasp R: Normal Weak Absent Grasp L: Normal Weak Absent Pupils R: ___mm Sluggish Brisk Fixed Pupils L: ___mm Sluggish Brisk Fixed
Peripheral Pulse: Present Upper Lower Edema Location: Basic Rhythm:
Gastrointestinal Abd: Soft Non Tender Tender Bowel Sounds X4 Hyper Hypo Absent Stool/Appearance:_______ Ostomy:______ NGT cont intermittent clamped Incontinence
Respiratory Even
Unlabored
Uneven
Genitourinary
Labored SOB SOB with exertion Lungs: Clear Bilateral Abnormal Lung Sounds
Urine: Clear Incontinence
Cough:
Gait: Steady With Assist Unsteady Device: Crutches Walker Cane Traction Type:_______ Ck:q______hours CMS checks every_____ hrs within normal
Productive Nonproductive Sputum: Color ________ Amount:_____________ Consistency:__________ Suction:______________ O2: NC____Liters Mask Vent Trach Psychological Calm Anxious Depressed
Cooperative
Restless
Sensory Visual impairment: Yes No Auditory impairment: Yes No If yes, describe:
Surgical Site Location:________ Dsg Clean & Dry Changed Incision: Approximated no s/s infection Redness Drainage
Musculoskeletal
Integumentary
Combative
Numbness or tingling
Cloudy
Warm Cool Diaphoretic Color______ Preventative Measures Breakdown
Special Skin Care:________________
NSU Nursing Dept.
8
Adult Nursing Courses
CONCEPT MAP
Sinai Martinez
Nursing Dx: Nursing Dx: Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation.
Ineffective Tissue Perfusion: related to decreased blood flow
Nursing Dx: Activity intolerance related to imbalance between oxygen supply and metabolic needs of tissues.
Reason for Seeking Health Care
Chest pain
References
Nursing Dx: Gulanick, M., & Myers, J. (2009). Online care plan constructor. Nursing care plans: Nursing diagnosis and Nursing Dx: intervention (6th ed.). Retrieved February 27, 2010 from http://www1.us.elsevierhealth.com/ME...ex.cfm?plan=02
NURSING INTERVENTIONS
NSU Nursing Dept.
9
Adult Nursing Courses
Priority #1 Nursing Diagnosis: Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation. Intervention(s) 1. The nurse will Perform 12 lead EKG or 24 lead as ordered. 2. The nurse will Observe the patient’s vital signs three times a day. 3. The nurse will ister Oxygen Therapy as ordered. 4. The nurse will ister Nitroglycerin every 5 minutes for chest pain up to 3 times until relieved. 5. The nurse will assess patient chest pain every hour and educate the patient on reporting an increase in chest discomfort.
Expected Outcome (Client Response) Patient will maintain normal sinus rhythm during hospitalization. The patient will maintain a heart rate between 60-100 and a BP below 120/80 in 3 hours. The patient will feel relief of chest pain within 3 hours. The patient will feel relief of chest pain within 3 hours. The patient will verbalize a pain level of 2 or below within 3 hours.
Priority #2 Nursing Diagnosis: Ineffective Tissue Perfusion related to decreased blood flow Intervention(s) 1. The nurse will implement the collaboration of oxygen and delivery of analgesic drugs as ordered. 2. The nurse will asses the patients vital signs three times a day
Expected Outcome (Client Response) The patient will feel relief of chest pain within 3 hours.
3. The nurse will observe for signs of complications of chest pain.
There will be no significant complication for 24 hours.
The patient will maintain a heart rate between 60-100 and a BP below 120/80 in 3 hours.
Priority #3 Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and metabolic needs of tissues. Intervention(s) 1. The nurse will keep the patient on bed rest in Fowler position / semi-Fowler. 2. The nurse will Observe and record vital signs three times a day. 3. The nurse will Reduce environmental stimuli to the patient. 4. The nurse will observe for signs and symptoms of complications related to chest pain 5. The nurse will acquire blood samples for cardiac enzyme levels.
Expected Outcome (Client Response) The patient will feel relief of chest pain while in bed within 30 minutes. The patient will maintain a heart rate between 60-100 and a BP below 120/80 in 3 hours. The patient will enjoy a relaxed environment without stress resulting in reduced chest pain within 3 hours. There will be no significant complication for 24 hours. The patient’s blood will show normal Troponin levels in 12 to 16 hours
1
Adult Nursing Courses
Report Worksheet Student’s Name: __Sinai Martinez_______________ Date___2/14/2013_ Client Initials ___R. M_____Room _____527___ Date of ission ___2/18/2013______ Age __65___ Gender: M_X_ F___ Religious Preference_Catholic______ Ethnicity______Hispanic____ Medical Dx _______Angina_____ Diet ____NA restriction________Weight __205_____ Activity ____Regular___Allergies _NKA___ Primary RN _____Julia_RN____ THURSDAY
FRIDAY
Time
Tem p
Puls e
Repor t 0800 1200
97.9
70
98.6 98.8
66 69
Respiratio ns
Report from RN
Things to Do
18
Blood Pressur e 130/90
Pain Ratin g 3
17 17
128/80 126/80
3 0
Time
Tem p
Puls e
Respiratio ns 15
Blood Pressur e 143/87
Pain Ratin g 0
Repor t 0800 1200
98.0
77
98.8 98.6
80 78
17 16
138/86 129/80
0 0
Report from RN
Things to Do
NSU Nursing Dept.
2
Adult Nursing Courses
MEDICAL/SURGICAL HISTORY Medical Diagnosis (Reason for seeking health care): _____Angina____
Medical History
Correlation to Medical Dx/Reason for seeking health care
Chest pain
Chest pain is a symptom of angina caused when the coronary arteries aren’t getting enough oxygen.
Hypertension
High blood pressure can be a result of the vessels being blocked or constricting.
Surgical History
Correlation to Medical Dx/Reason for seeking health care
N/A
PATHOPHYSIOLOGY Medical Diagnosis (Reason for seeking healthcare): __Angina__ Textbook description of pathophysiology and clinical manifestations relating to client’s primary disorder Angina pectoris is a clinical syndrome usually characterized by episodes of pain in the anterior chest. The cause is insufficient coronary blood flow. Resulting in decreased oxygen supply when there is an increase myocardial demand in response to physical exertion or emotional stress.
Reference: Smeltzer, C. S., Bare, G. B., Hinkle, L. J., Cheever, H. K. (2008) Brunner & Suddarth’ Textbook of Medical-Surgical Nursing. Philedelphia, PA: Lippincott Williams & Wilkins.
Comparison with client data (subjective & objective) Subjective: Patient proclaims pain on exertion, when exposed to cold, when eating heavy meals, and when stressed. Pain radiates to jaw. Objective: SOB, pallor, nausea and vomiting,
NSU Nursing Dept.
Date
3
Adult Nursing Courses
Lab Study
Current La b Val ues
Normal Values
Previous/ ission Data
Significance of abnormal values
2/14/13
SIGNIFICANT LABORATORY DATA DIAGNOSTIC TESTING Test (Include the Date) ECG (2/12/13)
Nursing Interventions (Pre & post procedure nursing care) Educate the patient on the procedure. Let them know that it will be non invasive. Leads will be placed on the chest and electrical impulses will monitor the hearts condition.
Results & Nursing Implications Shows T-wave inversion which can be attributed to changes indicative of ischemia.
NSU Nursing Dept.
4
Adult Nursing Courses
Routine IV fluids Type of Fluid (Identify as Hypo/Hyper/Isotonic)
Rate
Location of IV Site
Assessment of IV Site
N/A
MEDICATIONS (List all Routine Medications currently ordered for the client) Generic/Trade Name
Dosage
Route
Frequency (times to be istered)
Nitroglycerine/ Nitrates
Patch
Therapeutic Drug Classification
TID
Nursing Process Assessment & Interventions
Nitrate
MEDICATIONS (List all PRN Medications currently ordered for the client) Generic/Trade Name
Dosage
Route
Frequency
Therapeutic Drug Classification
Nursing Process Assessment & Interventions
NSU Nursing Dept.
Thursday’s Assessment Sheet Cardiovascular Apical Pulse: Regular Irregular
Neurological Oriented: Date Time Disoriented Unresponsive
5
Adult Nursing Courses
Awake
Alert
Lethargic
Speech: Clear Garbled Slurred Appropriate Aphasic Inappropriate ROM: Full Limited: Complete Below Facial Droop: Right Left None Left Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Numbness or tingling Right Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Left Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Right Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Grasp R: Normal Weak Absent Grasp L: Normal Weak Absent Pupils R: ___mm Sluggish Brisk Fixed Pupils L: ___mm Sluggish Brisk Fixed
Peripheral Pulse: Present Upper Lower Edema Location: Basic Rhythm:
Gastrointestinal Abd: Soft Non Tender Tender Bowel Sounds X4 Hyper Hypo Absent Stool/Appearance:_______ Ostomy:______ NGT cont intermittent clamped Incontinence
Respiratory Even
Unlabored
Uneven
Labored SOB SOB with exertion Lungs: Clear Bilateral
Cough:
Productive Nonproductive Sputum: Color ________ Amount:_____________ Consistency:__________ Suction:______________ O2: NC____Liters Mask Vent Trach Psychological
Anxious Depressed
Cooperative
Urine: Clear Incontinence
Cloudy
Musculoskeletal
Abnormal Lung Sounds
Calm
Genitourinary
Gait: Steady With Assist Unsteady Device: Crutches Walker Cane Traction Type:_______ Ck:q______hours CMS checks every_____ hrs within normal Integumentary
Restless
Combative
Sensory Visual impairment: Yes No Auditory impairment: Yes No
Warm Cool Diaphoretic Color______ Preventative Measures Breakdown Special Skin Care:________________
NSU Nursing Dept.
Adult Nursing Courses
If yes, describe:
Surgical Site Location:________ Dsg Clean & Dry Changed Incision: Approximated no s/s infection Redness Drainage
6
NSU Nursing Dept.
Neurological Oriented: Date Time Place Disoriented Awake Unresponsive
7
Adult Nursing Courses
Friday’s Assessment Sheet Cardiovascular Apical Pulse: Regular Irregular Alert
Lethargic
Speech: Clear Garbled Slurred Appropriate Aphasic Inappropriate ROM: Full Limited: Complete Below Facial Droop: Right Left None Left Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Right Upper Extremity: Against Resistance Against Gravity Involuntary Flaccid Left Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Right Lower Extremity: Against Resistance Against Gravity Involuntary Flaccid Grasp R: Normal Weak Absent Grasp L: Normal Weak Absent Pupils R: ___mm Sluggish Brisk Fixed Pupils L: ___mm Sluggish Brisk Fixed
Peripheral Pulse: Present Upper Lower Edema Location: Basic Rhythm:
Gastrointestinal Abd: Soft Non Tender Tender Bowel Sounds X4 Hyper Hypo Absent Stool/Appearance:_______ Ostomy:______ NGT cont intermittent clamped Incontinence
Respiratory Even
Unlabored
Uneven
Genitourinary
Labored SOB SOB with exertion Lungs: Clear Bilateral Abnormal Lung Sounds
Urine: Clear Incontinence
Cough:
Gait: Steady With Assist Unsteady Device: Crutches Walker Cane Traction Type:_______ Ck:q______hours CMS checks every_____ hrs within normal
Productive Nonproductive Sputum: Color ________ Amount:_____________ Consistency:__________ Suction:______________ O2: NC____Liters Mask Vent Trach Psychological Calm Anxious Depressed
Cooperative
Restless
Sensory Visual impairment: Yes No Auditory impairment: Yes No If yes, describe:
Surgical Site Location:________ Dsg Clean & Dry Changed Incision: Approximated no s/s infection Redness Drainage
Musculoskeletal
Integumentary
Combative
Numbness or tingling
Cloudy
Warm Cool Diaphoretic Color______ Preventative Measures Breakdown
Special Skin Care:________________
NSU Nursing Dept.
8
Adult Nursing Courses
CONCEPT MAP
Sinai Martinez
Nursing Dx: Nursing Dx: Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation.
Ineffective Tissue Perfusion: related to decreased blood flow
Nursing Dx: Activity intolerance related to imbalance between oxygen supply and metabolic needs of tissues.
Reason for Seeking Health Care
Chest pain
References
Nursing Dx: Gulanick, M., & Myers, J. (2009). Online care plan constructor. Nursing care plans: Nursing diagnosis and Nursing Dx: intervention (6th ed.). Retrieved February 27, 2010 from http://www1.us.elsevierhealth.com/ME...ex.cfm?plan=02
NURSING INTERVENTIONS
NSU Nursing Dept.
9
Adult Nursing Courses
Priority #1 Nursing Diagnosis: Acute pain related to tissue ischemia secondary to arterial occlusion, tissue inflammation. Intervention(s) 1. The nurse will Perform 12 lead EKG or 24 lead as ordered. 2. The nurse will Observe the patient’s vital signs three times a day. 3. The nurse will ister Oxygen Therapy as ordered. 4. The nurse will ister Nitroglycerin every 5 minutes for chest pain up to 3 times until relieved. 5. The nurse will assess patient chest pain every hour and educate the patient on reporting an increase in chest discomfort.
Expected Outcome (Client Response) Patient will maintain normal sinus rhythm during hospitalization. The patient will maintain a heart rate between 60-100 and a BP below 120/80 in 3 hours. The patient will feel relief of chest pain within 3 hours. The patient will feel relief of chest pain within 3 hours. The patient will verbalize a pain level of 2 or below within 3 hours.
Priority #2 Nursing Diagnosis: Ineffective Tissue Perfusion related to decreased blood flow Intervention(s) 1. The nurse will implement the collaboration of oxygen and delivery of analgesic drugs as ordered. 2. The nurse will asses the patients vital signs three times a day
Expected Outcome (Client Response) The patient will feel relief of chest pain within 3 hours.
3. The nurse will observe for signs of complications of chest pain.
There will be no significant complication for 24 hours.
The patient will maintain a heart rate between 60-100 and a BP below 120/80 in 3 hours.
Priority #3 Nursing Diagnosis: Activity intolerance related to imbalance between oxygen supply and metabolic needs of tissues. Intervention(s) 1. The nurse will keep the patient on bed rest in Fowler position / semi-Fowler. 2. The nurse will Observe and record vital signs three times a day. 3. The nurse will Reduce environmental stimuli to the patient. 4. The nurse will observe for signs and symptoms of complications related to chest pain 5. The nurse will acquire blood samples for cardiac enzyme levels.
Expected Outcome (Client Response) The patient will feel relief of chest pain while in bed within 30 minutes. The patient will maintain a heart rate between 60-100 and a BP below 120/80 in 3 hours. The patient will enjoy a relaxed environment without stress resulting in reduced chest pain within 3 hours. There will be no significant complication for 24 hours. The patient’s blood will show normal Troponin levels in 12 to 16 hours
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