Concept Map Template NURS 3073

Student Name:

Client: 69A Age: 52 Room: DOA: Code status: Full Code Allergies: Penicillin
Reason for hospitalization: Sepsis, CNS embolism?
Priority assessments: Neurological, circulatory, skin, respiratory
Significant history: Cervical spinal stenosis, UGIB, polyarthralgia, hypothyroidism, systemic lupus?

Nursing diagnosis: Ineffective cerebral tissue perfusion related to endocarditis secondary to staph/strep
bacteremia from open skin to right foot

Supporting data: cerebral emboli, cytotoxic edema to occipital lobe, CT findings of acute/subacute infarction, culture
negative endocarditis posterior reversible encephalopathy syndrome (PRES), D dimer: 2189 (<=500), altered LOC

Goals: Pt will not display any signs of further deterioration or increased ICP

Interventions:

-Monitor and document neurologic status frequently and compare with baseline. (e.g., GCS)

-Monitor vital signs: Hypertension/hypotension

-Respirations, noting patterns and rhythm;
 (e.g., Cheyne-stokes respiration- rhythmic respiration with periods
of apnea and may indicate dysfunction in the cerebral hemisphere or basal ganglia)

-Document changes in vision and pupillary changes

-Assess for nuchal rigidity, twitching, increased restlessness, irritability, onset of seizure activity

-Administer medications as ordered

Outcomes
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Nursing diagnosis: Acute pain related to polyarthralgia and ulceration to left foot

Supporting data: polyarthralgia, 5-6 bullae to right foot, ~2.0x1.0cm ulceration to left foot, purpura and ecchymosis to
left foot, order for oxycodone, pt report of “poor pain control to legs”, pt reports of 8/10 pain, systemic lupus?

Goals: Patient describes satisfactory pain control at a level less than 3 to 4 on a rating scale of 0 to 10.

Interventions
-Assess patients pain using pain scale
-Assess for signs and symptoms related to pain
-Administer pain medications as ordered and PRN pain
-Assess patients’ goals for pain relief
Outcomes
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Nursing diagnosis: Risk for Infection related to inhibition of antibodies secondary to immunological system
action

Supporting data: sepsis, endocarditis, predisposition to bacteremia (endocarditis), saline lock, nosocomial infection,
suprainfection, ~2.0x1.0cm ulceration to left foot, neuts: 7.30

Goals Patient will be free of infection, afebrile, with no over symptoms of infection or infective process noted.

Interventions
-Monitor temperature q4h
-Monitor for signs and symptoms of deterioration
-Observe for symptoms of suprainfections such as white plaque in mouth and irritation to vagina
- inspect wounds, IV sites, catheter sites, invasive devices and lines, changes in drainage or body fluids
-administer antibiotics as ordered

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Diagnostics/lab data (Identify data most relevant to interventions/diagnosis above)
-CRP: 24.5 (<=5.0)
-ERC: 2.85
-Hgb: 84
-HCT: 0.256
-Neuts: 7.30
-eos: 0.50
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Medications (Identify all meds. Note meds relevant to priority nursing diagnoses & those required for overall management)

Nicotine 1mg/spray 1spray, q1h, PO, PRN nicotine craving

-Class: smoking deterrents
-provides source of nicotine during withdrawal

Enoxaparin injection 40mg SC q24hr (prophylaxis)

-Class: anticoagulants, antithrombotic, low molecular weight heparin
-Mechanism of action: prevention of thrombus formation, potentiates the inhibitory effect of antithrombin on
factor Xa and thrombin
-Indication: prevention of DVT or PE, treatment of DVT with or without PE

Oxycodone 5-10mg PO q4h (18,22) PRN Pain (HOME)

-Class: opioid analgesic
-Action: binds to opioid receptors in the CNS
-Onset: 10-15, peak: 60-90, 3-6hr
Side effects: confusion, sedation, constipation

Acetaminophen 975mg PO q6h

-Class: antipyretic, nonopioid analgesic
-Mechanism of action: inhibits synthesis of prostaglandins that serve as mediators of pain and fever
-Indication: mild pain, fever
-Side effects: nausea
-Onset: 0.5-1hr
Oxycodone CR 60mg PO BID
-Class: opioid analgesic
-Action: binds to opioid receptors in the CNS
-Side effects: confusion, sedation, constipation

Zoplicone 15mg PO bedtime, PRN sleep

-Class: sedative, cyclopyrrolones
-Mechanism of action: interacts with GABA-receptor complexes
-Indication: short term management of insomnia
-Side effects: bitter taste
-Onset: rapid

Levothyroxine 75mcg PO daily (HOME)

-Class: thyroid preparations
-Indications: hypothyroidism
-Action: replacement of endogenous thyroid hormones, increase metabolic rate of body tissues
-Side effects: only in excessive doses cause hyperthyroidism

Atenolol 100mg PO daily (HOME)

-Class: beta-blocker
-Action: blocks stimulation of beta1 adrenergic receptors, decreases BP and HR
-Onset:1hr, 2-4hr, 24hr
-Side effects: fatigue, weakness, erectile dysfunction

Pantoprazole sodium EC – 40mg, PO, BID (HOME)

-Class: antiulcer agents, proton pump inhibitors
-Mechanism of action: binds to an enzyme in the presence of acidic gastric pH, preventing the final -
transportation of hydrogen ions in the gastric lumen
-Indication: GERD
-Side effects: headache, hyperglycemia

Hydroxyzine 25mg PO (1700) AND 50mg PO q24hr (HOME)

-Class: antianxiety agent, antihistamine
-Action: acts as a CNS depressant at the subcortical levels of the CNS, blocks histamine 1 receptors
-Onset: 15-30min, 2-4hr, 4-6hr
-Side effects: drowsiness, dry mouth

Baclofen 5mg PO TID PRN spasticity (HOME)

-Class: antispacicity agent, skeletal muscle relaxant
-Action: inhibits reflexes at the spinal level
-Side effects: dizziness, drowsiness, fatigue, weakness, nausea

Metoclopramide 10mg PO TID PRN N/V (HOME)

-Class: antiemetic
-Action: blocks dopamine receptors in the chemoreceptor trigger zone of the CNS, stimulates motility of the
upper GI tract and accelerates gastric emptying
-Onset: 30-60min, duration:1-2hr
-Side effects: drowsiness, extrapyramidal reactions, restlessness