‘Cede or Concept Map _ Key Problems/Nursing Diagnosis & Supporting Evidence 1.) Ineffective Cerebral Tissue Perfusion/Ineffective Tissue Perfusion GCS of 3 per EMS prior to admission PRN BP (hydralizine 10mg IV Q30min PRN SBP >160, labatolol 10mg IV SBP >160 Q4H PRN) serial neurological checks (plan documented 10/10) glucose regulation (insulin lispro sliding scale starting at 140 with 2 units) diet feed volume based on NPO fluid restriction (start at 25mV/hr and increase by 25 mi/nr Q4H until reach rate=volume ordered/duration ordered) control pain to prevent BP increasing Head CT w/o contrast 10/10: intraparenchymal hemorrhage multifocal areas, subarachnoid blood products, subdural hemorrhage and fracture of interior occipital condyle Head CT 10/10 (2nd): worsening of multiple sites of acute intracranial hemorrhage/intraparenchymal hematoma overall stable Head CT 10/11: large amount of blood/luid left sphenoid and moderate amount in right sinus 10/12: Increase Na and Cl (148 and 113) (NPO, low water intake, higher concentration) monitor urine output (need at least 30m! per hour) 10/12: elevated CK (found in brain) altered mental status/inconsistent with following commands (day of care 10/12) hx of at least two seizures per EMS prior to admission (Keppra 500mg/100m! IVPB Q12H) 10/10 plan: no anticoagulant (d/t bleeding) GCS <7 metoprolol 2.5 ml injection scheduled extubation followed by reintubation (inability to breathe effectively on own) impulsive/ poor judgements new onset Atrial Fibrillation (Cardizem bolus and IV gtt/Cardiac consult) (inadequate ventricular filling/decreases stroke volume by 25%) 2.) Ineffective Airway Clearance/mpaired Gas Exchange intubation with ETT size 8.0 lip-line 24 AC mode/ Rate 14/ Fi02 40%/ TV 450/ PEEP 5 monitor SPO2 respiratory failure followed by reintubation (weaning failure/increase mortality) reintubation with subsequent tracheostomy (#8 shirley, 28 french) spontaneous mode/rate varies/ Fi02 40/ PEEP 5/ PSV 10 cmH20/ dilator/ T piece 12 liters moderate tan thick secretions Punpwakory MKtlon7suctioning PRN (dropping 2 sat < 90, rises after suctioning) duoneb (ipratroprum-albuterol) 1 ampule Q4H while awake 10/17: increased cough, leukocytosis, respiratory failure 10/22 Bronchoscopy with purulent fluid/moderate secretions MSSA in sputum 10/17 CXR: progressive opacification of left lung with new airspace opacity in left lung with new airspace opacity in left upper lung most consistent with progressive infiltrate, continuous dense consolidate changes involves left lower lobe and probable small left pleural effusion 10/18 CXR: stable/recommended clinical correction/ improving but persistent patchy right lower lobe airspace opacity 10/22 Febrile 10/26 hemoglobin of 8.4 and hematocrit of 25.8 Augmentin 250 mg Q6H 3.) Risk For Injury seizure prophylaxis (Keppra) restless (grabbing at trach, PEG, and other lines) need for two point restraint risperidone (Risperedal) 1 mg BID (antipyschotic/aggression and irritability) lorazepam (Ativan) 0.5 mg BID (benzodiazepine/anxiety) propofol 1000mg/100 mi IV (sedation/ETT) 10/13: “impulsiveness/poor judgment” lower extremity weakness hx of falls (alcoholism) 4, Risk For Infection invasive tubes and lines/prolonged period of time (foley, ETT/rach, peripheral IV, Central Line) long term hospitalization (>2 weeks) VAP prophylaxis (mouth care, sedation vacation, HOB 30-45 degrees, PPI/ pantoprozole, DVT prophylaxis/10/25 after bleeding stable) sedentary/impaired mobility secretions/need for suctioning (sterile) turn Q2H (prevent skin breakdown/ulcer/necrosis) chlorhexidine 0.12% 15 mL BID *risk evident 10/12 during first time caring for, subsequent infection developed upon second time caring for 40/22: Bronchoscopy (purulent fluid/moderate secretions) and Febrile 40/25: increased WBC of 16 (normal 4.5-11.5) MSSA in sputum and enterococcus in urine C Difficile Toxin A and/or B detected Vancomycin 250 Q6H amoxicillin clavulanate 500mg Q8H increase neutrophil to 12.65 (1.80-7.30)5.) Risk For Impaired Nutrition NPO low Albumin of 2.2, 2.3 (normal 3.5-5.2) low calcium at 7.7 (8.6-10.2 chronic alcoholism (damaged liver/ increased ALP 229) need for PEG Tube and tube feedings multivitamin with iron mineral liquid oral daily pantoprozole (Protonix) 40mg IV daily (ulcer prophylaxis) folic acid injection 1 mg IV thiamine (B-1) injection 100mg IM daily altered mental status (ability to eat by self upon discharge to long term facility questionable) _ ondanestron (Zofran) 4 mg IV PRN for nausea (possible vomiting r/t head injury) 6.) Pain docusate (Colace) 10 mL oral BID and senna (Senokot) 5mL for bowel movement (prevent constipation and straining/prevent raising BP) fentanyl (Sublimaze) 5 mcg/ml in 0.9% NS 100mL infusion oxycodone (Roxi) 5 mg or 10 mg PRN Q4H occipital bone fracture cervical collar insertion of various lines (PEG tube and teach most recent) 7.) Interrupted Family Process finding long term care facility (one that takes trachs) concern for return to normalcy and effect on future mental status frustration with injury rt alcoholism (wife vocalizing she should've left him a long time ago/ “he's always been a drunk”) ‘stress on daughter (flew in from a different state/away from her family) 8.) Hopelessness long term hospitalization (>2 weeks) altered mental status lack of mobility/strength two point restraints (unable to move hands freely paired with lower extremity weakness) connected to various tubes and lines (Central Line, Urinary Foley Catheter, PEG Tube/feeling trapped”)