Concept Map Ppw 3-4 Wk

8/3/2019 Concept Map Ppw 3-4 Wk

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2/16

Colace100mgP

O1xday:Docusateisa

pass.Sideeffect

s:rectalbleedingorirrit

diarrheaorstom

achcramps;orcontinu

Pt.isonthisme

d.toavoidstrainingan

Protonix(Pantoprazole)40mg/IV/1x

secretionandi

ncreasesgastricmucus

coatingongastricmucosa.

Patientisonth

istopreventincreasei

Majorsideeffe

cts:Abdominalpain,c

h

Flonasefluticasonepropionate)NasalSpray,1sprayineachnostril

discha

rge.Runnynose,stomachpain,

diarrh

ea,Flu-likesymptoms,

preventsthereleaseofsubstancesinthebo

dythatcauseinflamma

conge

stion,sneezing,andrunnynosecause

dbyseasonaloryear-r

Hemoglobin (Hgb) Purpose/definition: Hemoglobin is what gives the red color to your

blood. It contains the iron, which carries the oxygen to the cells. The hemoglobin level

indicates the amount of intracellular iron; hence, its value in determining anemia.Norma

range: 14.0 to 15.0 g/dl Results: 14.5 g/dl Low Significance in patient & nursing implicati

Low levels of Hgb would indicate anemia, or loss of blood, which will prevent adequate t

perfusion and result in ischemia causing more damage to the brain tissue.

Hematocrit (Hct) Purpose/definition: The most precise methods of determining the deg

or polycythemia (excessive amount of red blood cells). The hematocrit represents the v

blood cells in 100ml of blood and is therefore reported as a percentage. Normal range: 4

Results: 45% WNL Significance in patient & nursing implications: If Hct level decrease en

increase causing decrease in tissue perfusion.

Ammonia test: is primarily used to help investigate t

changes in behavior and consciousness. Significantly

concentrations of ammonia in the blood indicate thaeffectively metabolizing and eliminating ammonia b

the cause. Norma levels 10-40 mol/L, results 27 m

ammonia levels increase significantly this affects the

RBC Purpose/definition:This test is a count of the number of circulating RBCs in 1mm3 of pe

venous blood. RBCs act as the transport and exchange system for carrying oxygen to the tissu

carbon dioxide away from the tissues. Normal range: 4.70-5.25 million/mm3, Results: 4.87 mi

the RBC count is low, tissue perfusion is decreased and the brain tissue would become ischem


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WBC Purpose/definition: The total number of WBCs (leukocy

blood. The differential, which is the percentage of each type o

specimen. The purpose of WBCs is to fight infection and respo

Normal range: 4.5-10. mm3 Results: 5.3 mm3. The number of

find an infection. This helps identify early infection and preven

and prevent further damage to brain.


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Intracranial

Inju

Often ca

whi

Pt. sustained an IVH, large parenchyma

hemorrhage, SAH, depressed skull fracture, a

midline shift and an uncal herniation.

Ps

Medications

atedasaresultofthesesympto

ms.

POevery4hourasneeded

swhorequirehigherdoses

a,vomiting,sweating,

drugduetoincisionalpainr/t

slightlydifferentfromo

therform

sofinsulin

handsorfeet;or

ethirst,increasedurination,

legdiscomfort,

tiontolowerglucoselevelsR/T

tubefeedings,


5/16

preventsneezing,congestionandrunnynosesothatICPisnotelev

Norco:hydrocodonebitartrateandacetaminophen325mg/tablet/2tab

Indication:

Forthemanagementofseverepainin

opioid-tolerantpatien

ofopioids.

Majorsideeffects:lightheadedness,dizziness,sedation,naus

flushing,dy

sphoria,euphoria,

drymouth,andpruritus.Patientisonthis

craniotomy

procedure,andhelptodecreaseICP.

Insulindetemirisalong-actingformo

finsulinthatis

thatarenotman-made.sidee

ffect

swellinginyour

lowpotassium(

confusion,unevenheartrate,extrem

muscleweaknessorlimpfeeli

ng).Pt.isonthismedic

whichalsohelpstonotelevateICP.

Diagnostic Tests

l

ions:

issue

ree of anemia

olume of red

2.0 to 48.0%

ough, ICP will

he cause of

increased

t the body is nott do not indicate

ol/L. If the

brain adversely.

ripheral

es and

illion/mm3. If

ic

Diet:

Eat a healthy variety of foo

breads, meats and fish, and

consume at least on fruit an

meal. (1 cup of fruit or 100

dried fruit can be considere

group, 1 cup of raw or cook

juice, or 2 cups of raw leafyas 1 cup from the vegetable

the red meat in your diet wi

chicken and turkey (three o

turkey, or other poultry) th

iron to help rebuild the iron

during bleeding episodes (1

fish, cup cooked dry bean

peanut butter, is for the ma

as skin, blood cells, muscles

foods high in vitamin C is th

iron increases iron absorpti

plus three snacks per day. E

periods of hunger. Drink six

liquid each day (follow your

must limit the amount of li

Medication: The patient

medication he will be se

he needs to do if there i

regimen. Keep a written

when and why you take

aspirin, naproxen, or ibu

caregivers. Always take

Call your caregiver if yoif you feel you are havin

medicines until you disc

antibiotics, take them u

better.

Med list:

Lovenox

Colace 1

Flonase 1

ProtonixNorco 32

Levemir


6/16

es) in 1 mm3 of peripheral venous

f leukocyte present in the same

nd immediately to foreign invaders.

hite blood cells is sometimes used to

t hyperthermia, hypermetabolic state

Blood sugar levels should be tightly controlled by

normal levels. Hyperglycemia also adversely affec

promoting cerebral edema. Hyperglycemia has b

brain tissue acidosis, increasing infarct size. norm98mg/dL.


7/16

raumatic

y

use: damage to the brain from bleeding or swelling

ch results in Increased Intra Cranial Pressure.

23y/o male transported to the ED by EMS on 8/30/11 with a head

injury as a result of an assault with a tire iron.

Ineffective airway clearance R/T accumulation

of secretions & decreased LOCNsg. Dx.

s

ychosocial

At risk for aspiration (for entry of gastrointestinal

secretions, oropharyngeal secretions, solids or fluids into

tracheobronchial passages due to dysfunction or absence of

normal protective mechanisms).

Altered cerebral tissue perfusion R/T increased ICP

Discharge Planning


8/16

s: fruits, vegetables,

dairy products. Aim to

d on vegetable with each

fruit juice, or cup of

d as 1 cup from the fruit

ed vegetables or vegetable

greens can be consideredgroup.) replace most of

ith leaner cuts, such as

unces of cooked chicken,

ese contain protein and

stores you may have lost

ounce of meat, poultry or

s, 1 egg, 1 tablespoon of

intenance of tissue (such

, etc.) in adulthood.) Eating

e same as foods high in

on. Eat three small meals

at regularly to avoid

to eight (8 ounce) cups of

caregiver's advice if you

uid you drink).

will be instructed on any of the

nt home with, their side effects and what

s any changes while on the medication

list of the medicines you take, the dose,

them. Do not take any medicine that has

profen in it without first asking your

your medicine as directed by caregivers.

think your medicines are not helping, org side effects. Do not quit taking your

uss it with your caregiver. If you are taking

ntil they are all gone even if you feel

Wound care: This pt has a

temporal to frontal lobe incision.

Review proper technique for

cleaning and taking care of the

incision with the family, teach

them the signs and symptoms of

possible infection, including

redness, warmth at site, swelling

of tissues, and drainage from

wound. Also teach the patient and

their caregiver about the effects of

anemia on the immune system

and how it will also delay wound

healing. Skin should be inspected

daily for breakdown or areas of

redness that do not blanch as this

Where is the patient bei

discharged to a rehabilit

be providing his transpo

Discharge

benefits t

medicatio

subcutan

plan of ac

dressing c

Activity: Set limits. There are

only so many hours in the day

and only so many things you

can do. Some things can wait.

Learn relaxation techniques

such as breathing exercises,

meditation or progressive

muscle relaxation. Wear ahelmet if participating in sports

or activities for which a helmet

is available

Follow up:

rehabilitat

scheduled

all appoin

needed. I

9627, neu

of an eme

30 mg Sub Q 1 x day

0mg PO 1 x day

spray in each nostril 1 x day

40 mg PO PRN5mg PO every 4 hrs.

2 units 1 x day


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using a sliding scale for insulin or an insulin infusion to maintain

ts the ischemic brain by disrupting the blood-brain barrier and

en associated with increased cerebral lactate resulting in local

al blood sugar levels are between 70 and 150 mg, results

may e a s gn o rea own an

possible decubitus ulcer

formation.


10/16

Pt. airway will be maintained patent by careful suctioning. AEB: pt. & family using suction apparatus to

clear secretion as needed.maintained patent by careful suctioning.

Elevate the HOB to at least 30 degrees to promote venous return and check frequently to make sure

the head is not lower than the body. AEB: Pt. in a semi fowlers position through out the day.

Monitor pt. LOC frequently to maintain patent airway, LOC will be at or above 13 in a Glasgow Coma

Scale. AEB: Pt. maintained a Glasgow score of 15.

Pt. will experience no aspiration and both pt. & family

will demonstrate techniques to prevent and/or correct

aspiration, suctioning as needed to clear secretions.

Pt. will avoid washing solids down with

liquids, and will eat slowly, while chewing

slowly and thoroughly, to prevent aspiration.

Pt. will not experience coughing, tachypnea, or

dyspnea, which are signs of aspiration after eating, ordrinking when he is advance to a soft/solid foods at the

end of the day.

AEB: Pt. respiration wa

breath sounds were cle

needed to be suctione

AEB: After

aspiration

Position the pt. with head slightly elevated and in

a neutral position to reduce arterial pressure and

promote venous drainage which will promote

Pt. will maintain a HR & Rhythm WDL, monitor HR & Rhythm, frequently,

noting bradycardia,alternating bradycardia & tachycardia, to prevent

dehydration, fever or hypermetabolic state which may increase ICP.

Monitor pt. BP frequently to maintain the BP WNL, noting onset of

and continuing systolic hypertension and widening pulse pressure.

AEB: Pt & f

head eleva

elevation t

uncomfort


11/16

ing discharged and who will assist? Patient will be

ation hospital with his family; mother and father will

rtation.

teachings:Discuss the importance of a healthy diet and the

e different food groups has on wound healing. Review

ns and administration technique for both PO's and

ous injections. Review signs and symptoms of infection and

ion if one is suspected. Review proper wound care and

hanging technique

: This patient is currently awaiting placement in a

ion hospital. Family will be instructed to maintain any

home visits from nurse. Ensure that the family maintains

tments and has the means to transport the patient if

nstruct patient to call Dr. Thomas Bragg III, (512) 454-

rosurgery, 711 W 38th St, Austin, TX 78705. In the event

rgency, call 911.


12/16


13/16

Goal met: Pt. airway maintained patent by using suction as needed,

his LOC remained at a Glasgow score of 15, and pt. and family

verbalized the understanding of keeping the HOB at a 30 degree

angle or higher.

s noiseless and unlabored, his

ar, and no secretions that

.

AEB: Pt. was advanced to soft/solid foods, he was able to

demonstrated how to chew his food slowly and thoroughly, he

verbalized that to prevent aspiration he would have to avoid

washing his foods down with liquids.

eating dinner, the pt. did not experience any signs of

such as coughing, tachypnea or dyspnea.

Goal Met: Pt. respiration was noisless

pt. was advance to soft/solid foods w

slowly avoiding liquids to wash his foo

aspiration such as coughing, tachypne

AEB: BP

8 am: 121/69

12pm: 119/42

5pm: 132/77

AEB: HR

8am: 88

12pm: 84

5pm: 82

amily verbalized the importance of keeping his

ted, the HOB was at a 30 dgeree or high

hroughout the day, pt. did not appear to be

able with HOB elevated.

Goal Met:Pt. BP remained WNL, there was

bradycardia, alternating bradycardia & tac

remained at a 30 degree elevation through

which was confirmed by pt. and family.


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& unlabored, with breath sounds clear;

hich he demonstrated how to chew

d down, pt did not show any signs of

a or dyspnea.

no signs of

hycardia, the HOB

out day and night

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