Natalia Trevino Original document with all my info

week 1 concept map

This is the PDF format that I am missing half the map with, when I go to save the map this is what it gives me

Natalia Trevino

week 1 concept map

Fluid Volume deficit administer IV fluids as needed (250ml bolus q4h) encourage PO fluids strict I&O Daily weight Monitor electrolytes (give 20 meQ potassium) Give oral care PRN GOAL: Balanced I&O, good skin turgor

Injury potential due to fatigue/weakness Assist with ADL's fall risk calculated and arm band applied Keep side rails up x2 GOAL: Patient free from injury and falls,remains free of injury, no injury noted

Ineffective tissue perfusion R/T decreased BP Admin vasoactive med as prescribed ( Neosynephrine 60 mcg titrated to MAP of 65) IV bolus as prescribed (250 ml q 4 h) Monitor VS q15 min Admin oxygen as prescribed (4l via NC,decrease PRN) GOAL:Blood pressure within acceptable limits, Neo off at 1630 ,SBP

66 y/o M C/O : Bil shoulder pain, SOB, Hypotension, nausea, vomiting, diarrhea x3 days HX: CHF, HTN, COPD,

Potential for electrolyte imbalance monitor lab levels Administer 20MEQ potassium Monitor EKG Monitor VS GOAL: electrolytes at optimal level, Potassium at 4.0

CAD, DM, chronic renal failure DX: Hypovolemic Shock

Assessment: 269 lbs , 4l oxygen via NC, Expiratory wheeze auscultated in Bil upper lobes, and right mid lobe of the lung, diminshed breathsounds in Bil lower lobes of the lung. Distant heart sounds auscultated. Pulses 3+ and irregular. A&O x3, speech clear, Foley to BSD VS: 84/46 BP, pulse rate 130, respirations 14 with 96% Oxygen sat, Blood sugar 136 Labs: Potassium 3.3, BUN 100, Creatinine4.05, GFR 15

Desired outcomes:
VS to baseline output >30ml/h Free of injury and falls Electrolytes at optimal level