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Tests Medications and Teaching: Concept Map Level 4
Tests Medications and Teaching: Concept Map Level 4
Level 4
Shift report: 3/8/06: Jane Doe female admitted 3/6/06 through the ER. Dx of vomiting, Hyponatremia (low serum sodium concentration) and prerenal azotemia (Prerenal azotemia is an
abnormally high level of nitrogen-type wastes in the bloodstream). Medical hx of CAD, MI x5, DM type 2, PVD, HTN and cholecystectomy (removal of the gallbladder). Allergic to codeine,
full code status, IV (L) hand NS 75ml/hr, full liquid diet, BRP w/assist, I&O q shift, LBM 3/4/06, nurse aide reported BP of 63/45 w/dinamap. Primary nurse and I both took a manual BP of
118/64. 3/9/09: 1800 ADA diet, saline lock (L) arm, night shift nurse withheld Toprol b/c BP was 107/48, LBM 3/8/06 diarrhea in the evening.
History of present illness: J.D. presented to the ER with 1-week malaise, general abdominal pain, nausea and vomiting. ER lab reported leukocytosis. IV zofran was administered, but did
not control the nausea and vomiting. Pt was admitted.
Assessment
System
Findings-include assessment, labs and dx
tests
A&Ox3
Neuro
Sensory function WNL
Cardiac
Resp
GI
GU
Pathology explanation
WNL
Nursing implications-include
medications and teaching
Continue to assess and monitor q shift and prn for mental
status changes or other neuro changes.
Musc-skel
Integ
Endocrine
Psychosocial
you need to correct the source of the problem, which workload, instruct pt to avoid straining. Promote physical
is reduced blood flow.
and emotional rest. Encourage deep breathing for
adequate tissue oxygenation.
Kaon-CL (KCL) 10meq PO qAM
WNL
Pt has family/friends that visit. She lives alone. She does Nutrition problems in the elderly can be common,
not drink alcohol. She is knowledgeable about her medical could be due to financial resources or knowledge
hx conditions, though she seems to lack knowledge
deficit on nutrition facts.
regarding nutrition. She suffers from insomnia sometimes.
Discharge planning: indicate likely patient needs or ongoing problems on discharge. Nursing actions to provide for those needs.
Need: Pt needs teaching regarding how to prevent constipation.
Action: Help pt to understand and know that certain medications can have a constipating
side effect. Send home with her a cup with measurement on it just like she used in the hospital.
Prioritize: list your patients in order of priority; least stable to most stable: explain why
1.
2.
3.
4.
5.
J.J. 62yr old Caucasian female admitted 3/8/06, dx new onset seizure and UTI. Pt is A&Ox2, stays confused and cannot recall why she is in
Hospital. Husband w/Parkinsons at bedside, and she believes he was the one admitted. She called a friend to come get her and take her home.
Friend arrived and was able to give some history on both of them. Pt is alcoholic, but denied alcohol use on admission. Other circumstances
Alerted nurse to call adult protective services.
S.M. is a 64yr old Caucasian female admitted 3/8/06, dx of pneumonia w/hx of a stroke. Bilateral lung sounds rales/ronchi. V/S WNL. Bilateral upper
Extremities experienced ongoing uncontrolled movements.
C.G. 67yr old Caucasian female admitted 3/6/06, dx vomiting, Hyponatremia and prerenal azotemia. Hx of CAD, MI x5, PVD, DM type 2, HTN, cholecystectomy. V/S WNL
J.S. 55yr old Hispanic male admitted 3/5/06, dx acute cholecystitis, cholecystectomy on 3/6/06, V/S WNL, pt ambulates independently, d/c home 3/8/06.
R.H. 19yr old Caucasian male admitted 3/5/06, dx of (R) ankle infection, V/S WNL, pt ambulates independently, no wound, skin intact, d/c home 3/8/06.
Teaching:
GI teaching regarding nutrition to prevent constipation
Encourage pt to drink something warm in the mornings (cup of coffee) and something warm in the evenings (cup of tea). This will promote bowel activity.
Encourage pt to eat small frequent meals/snacks.
Encourage pt to eat supplement bars high in fiber for snacks.
Encourage pt to increase and to measure her liquids. Advise a minimum of 2000cc 2500cc/day. (ex: 7a-3p drink 150cc/hr to intake 1200cc/8hr). Provide pt
with small cup with measurement lines.
Instruct pt how to include more fiber in her diet (ex: avocado, blackberries, baked beans, raisin bran) and increase her fluid intake (ex: 2500cc/day)
Author Unknown