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Kristen Nii-Jensen

NURS 360
Concept Map
Desired Outcomes
1. Infection/Skin integrity (Gulanick & Myers,
p.951-953)
1: Patient remains free of local and systemic
infection AED absences of foul-smelling
wound exudate by discharge.

7. Altered fluid & electrolyte imbalance


Gulanick & Myers, (p. 262-265)
1. Patient will maintain electrolytes within
normal range when therapy is stable by
discharge.

3. Pain (Gulanick & Myers, p. 151-154)


1. Patient reports satisfactory pain control at
a level less than 3-4 on a 0-10 pain scale
by end-of-shift through current
hospitalization.

4. Risk for unstable glucose levels (Gulanick &


Myers, p.911-913)
1. Pt maintains blood glucose levels within
defined target ranges before discharge to
home.

Interventions
1. Assess wound for drainage, color of tissue,
odor.
2. Obtain wound cultures.
3. Assess patient for symptoms of sepsis.
4. Monitor temperature, WBC count, and
nutritional status.
5. Consult dietitian for assistance with highprotein diet conducive to wound healing.
6. Administer antibiotics as prescribed.
1. Monitor for manifestations of serum
electrolyte imbalance.
2. Monitor fluid losses and gains.
3. Observe and document serial laboratory
data: sodium, potassium, chloride,
magnesium, and calcium levels.
4. Monitor ECG for arrhythmias related to
electrolyte imbalances.
5. Obtain daily weights as increased fluids
dilutes electrolyte concentrations.
6. Administer desired electrolytes to correct
electrolyte imbalance as ordered.
1. Asses pain characteristics, quality,
severity, location, duration, onset,
precipitating, and relieving factors.
2. Provide periods of rest to facilitate
comfort, sleep, and relaxation.
3. Determine appropriate pain relief method
(pharmacological/non-pharmacological)
and provide/administer as appropriate.
4. Administer analgesics as orders,
evaluating effectiveness and observing for
any signs and symptoms of adverse
effects.
5. Notify physician if interventions are
unsuccessful or if current complain is a
significant change from the patients past
experiences of pain.
6. Instruct patient to report pain, and
evaluation and report effectiveness of
measure used.
1. Establish goals with patient for weight
loss, glucose levels, HbA1c, and exercise
2. Asses for signs of hyperglycemia.
3. Monitor blood glucose levels prior to
each meal and prior to bedtime.
4. Administer routine and sliding scale as
needed insulin according to blood glucose

Kristen Nii-Jensen
NURS 360
Concept Map
levels.
5. Instruct patient on procedure of assessing
blood glucose levels, drawing up insulin,
administering insulin to subQ areas, and
rotation of anatomical sites.
6. Refer patient to registered dietitian for
individuals diet instructions.
5. Risk for ineffective tissue perfusion (Gulanick
& Myers, p.308-310)
1. Patient maintains optimal peripheral
tissue perfusion as evidence by strong,
palpable pules, reduction in/absence of
pain, warm and dry extremities with
adequate capillary refill and prevention of
ulceration before discharge.

6. Deficient knowledge: Nature of and


management regimen of hypertension and
diabetes mellitus (Gulanick & Myers, p. 270-271,
914-917)
1. Patient demonstrates knowledge and
understanding of medication, disease
process of diabetes and hypertension, and
self-care before discharge.

1. Documents and asses presence or absence


and quality of all distal pulse, skin color
and temperature, presence of absence of
pain, numbness, tingling, movement and
sensation of all extremities.
2. Administer low-molecular weight heparin
as prescribed.
3. Do active range-of-motion exercises to
extremities as tolerated.
4. Keep extremities warm.
5. Instruct patient to immediately report
presences of increasing pain, numbness,
tingling and decrease of loss of sensation
and movement.
6. Immediately report to physician any
decrease or loss of pulse, change in skin
color and temperature, presence of pain,
numbness tingling, delayed capillary
refill.
1. Assess patient current knowledge of
disease process and care regimen.
2. Evaluate self-management skills,
including ability to monitor blood
pressure and blood glucose
3. Assess for factors that may negative affect
success of teaching.
4. Ensure patient has knowledge of
symptoms, causes, treatment and
prevention of
hyperglycemia/hypoglycemia and
hypertension/hypotension.
5. Refer to social services to help with
financial resources.
6. Evaluate effectiveness of teaching and
ensure patient understanding and ability
to return demonstrate skills learned.

Discharge Plan/Patient Teaching

Kristen Nii-Jensen
NURS 360
Concept Map

The patient is to be discharged to home with referral for a home healthcare nurse to assist
with wound vacuum. The patient currently lives with his girlfriend, and she currently works
during the day time. The patient should be provided with a cane to support right-side when
ambulating, as pain to the right upper thigh related to myelitis affects his gait. Other than this, the
patient is able to do nearly all self-care activities on his own, and his live-in girlfriend cooks and
assist with cleaning of the house.
The patient needs teaching on when to contact the surgery team concerning his wound
vacuum dressing, particularly when it losses proper seal. A home health care nurse can assist
with settings, maintenance of machine, emptying canisters, etc. As the wound vacuum dressing
is changed by the surgical team, the patient will need to be provided a strict follow-up schedule
to ensure dressing changes occur in a timely manner. This should be coordinated with his
girlfriend, and she provides travel by car.
The patient will need extensive teaching concerning his insulin regimen, blood glucose
checks, hypertension medication, obtaining blood pressures, dietary restrictions, follow-up
schedule, signs and symptoms of an infection, and when to seek acute medical attention. He is
set to return home after the sensation of his antibiotic regimen and is anticipated to have his
PICC line discontinued before discharge. However, it is anticipated that he will be sent home
with the wound vacuum. He needs to be directed when to contact the surgical team, and his
follow-up schedule for dressing changes.
He also needs extensive instruction on how to check his own blood glucose, how to draw
up insulin, sliding scales, routine doses, and areas to administer, how to administer into the
subcutaneous, and regions where he will cycle administration. He will also need instruction on
the signs and symptoms of both hyper and hypoglycemia, and what interventions he must do to
prevent further complications. Foot care and careful wound management is also warranted as he
has reported period of chronic toe numbness/paresthesia to prevent further injury and/or infection.
As his live-in girlfriend does the majority of the cooking, she will need to be included
when it comes to instructions on complying with a cardiac and diabetic diet. A consult with a
dietitian, recipe guidelines, and cultural consideration should be taken. Information on an
exercise regimen should also be provided to assist with the patient obesity.

Kristen Nii-Jensen
NURS 360
Concept Map

The patient reports he learns best via video, but direct tactile training should also be
integrated with extensive return demonstration. He will also need to learn how to take his own
blood pressure, when to take his blood pressure medication, and at what blood pressure should
he hold his own blood pressure medication.
As the patient has a history of medication non-compliance, efforts should be taken to
assess why he stopped taking or obtaining prescription medication. A social-work consult may
be needed if reasons are economic based. This may also be a factor in non-compliance with his
cardiac and diabetic diet.
As his follow-up schedule will be needed for wound care, myelitis to right thigh, and
with his endocrinologist, thus a calendar with upcoming appointments should be provided. The
patient should be directed to take his temperature, and be aware of chills, sweating, malaise, and
excess tiredness, pain to his clavicle wound or upper right thigh may indicate infection and he
should seek immediate treatment. Other things such as excess bleeding from wound site, excess
purulent exudate, acute hypo or hyperglycemia unresolved with glucose intake or insulin
administration should also warrant medical attention. As the patient needs a myriad of teaching
before discharge, discharge teaching should occur throughout his stay, and reinforced multiple
times.
Works Cited:
Gulanick, M., & Myers, J. L. (2011) Nursing care plans: Diagnoses, interventions, and
outcomes. (7th ed.). St. Louis, MO: Elsevier Inc.