Concept Map 2 by Cameron https://padlet.com/cameronj2016/bitouivvmjdd en-us 2019-03-24 17:29:07 UTC 2019-03-24 18:49:05 UTC hello@padlet.com Assessment cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583478 •Abdominal Aortic Aneurysm (AAA) s/p endovascular repair with persistent endoleak on 3/6
•Post-op day 12 s/p supra-celiac aorta to right renal artery
•Surgery complicated by colon ischemia post sigmoid colectomy and temporary closure of abdomen on 3/15
•Pt had a bowel perforation during surgery
•Suction right abdominal bulb drain- 15 mL fluid after 10 mL infusion
•Pain rated at 6 out of 10
•Incision was post healing, some blood when re-packing the wound
•Liquid diet
]]> 2019-03-24 17:30:36 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583478 Medications (PICC line) cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583592 •Tylenol 1,000mg PO q4h PRN for pain (0800, 1200, 1700)- pain control
•Heparin 5000 u subQ BID (0900, 2000) - prevent further blood clots
•Caspofungin 50mg in NaCl 0.9% IVPD daily (1800) -prevent fungal infections post bowel perf
•Cefepime in dextrose IVPB 200mL/hr daily (0900)- antibiotic preventing infection post bowel perf
•Fentanyl PCA 50mcg/mL continuous infusion- pain control
•Metronidazole in NaCl IVPD 200mL/hr q8h (0945, 1745, 0045) - antibiotic preventing infection post bowel perf
•Vancomycin in NaCl 0.9% IVPB 260mL/hr daily (0800)- antibiotic preventing infection post bowel perf
]]> 2019-03-24 17:31:20 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583592 Cameron Johnson cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583652 DEU Shift: 03/23/2019
0630-1730]]> 2019-03-24 17:31:52 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583652 S/S cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583716 •S: pain and discomfort from incision
•O: 10 inch abdominal incision left open for secondary healing, bulb drainage orange serosanguinous fluid, pt using PCA for pain control
•PMH: COPD, CAD, HTN
•Family History os transient ischemic attacks
]]> 2019-03-24 17:32:20 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583716 Bowel Perforation cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583768 77 y.o. male]]> 2019-03-24 17:32:45 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583768 Nursing Diagnosis 1 cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583841 Risk for infection r/t perforated bowel
  • Pt goal: pt will demonstrate proper care for cleaning own wound
  • Pt teaching: hand washing, infection preventative techniques, how to clean incision, regularly taking antibiotics
  • Potential complications: infection leading to sepsis
]]> 2019-03-24 17:33:23 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583841 Monitoring cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583905 •VS q4h
•Neuro checks
•Ostomy output
•Bulb drain output
•Incision output
•I&O after catheter removal
•Pain levels
•Labs: wbc count 26.7 (high), platelet count 33 (low), Hct 28.3, Hgb 8.9; continue monitoring these for bleeding and infection
•CT of abdomen and pelvis 3/25
]]> 2019-03-24 17:33:51 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583905 Nursing Diagnosis 2 cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583951 Risk for disturbed body image r/t new ostomy
  • Pt goal: pt will verbalize acceptance of new body image with ostomy
  • Pt teaching: teaching pt adaptive behavior to new ostomy and normalcy of body image disturbance
  • Potential complications: pt does not accept new body image and cannot cope
]]> 2019-03-24 17:34:09 UTC https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583951 SBAR cameronj2016 https://padlet.com/cameronj2016/bitouivvmjdd/wish/344583995 S: Patient is a 77 year old male, admitted to the med-surg floor for bowel perforation post care following surgery.
B: He was admitted on 3/6 for surgery to correct an Abdominal Aortic Aneurysm (AAA). This was complicated by colon ischemia post sigmoid colectomy and a bowel perforation. He has a history of COPD, CAD, and HTN.
A: As of 0800 3/23 his temperature was 36.6 C, heart rate was 68, respiratory rate was 28, blood pressure was 135/54, and pulse oximetry was 97%. His vitals have stayed regular throughout the day. He complains of extreme discomfort and sharp pains in his abdomen that he rates as a 6 out of 10. He has a PCA to deliver Fentanyl, but does not regularly use it. His catheter has been removed and he has been urinating into a urinal after given Furosemide. His stool collected in the ostomy bag is dark brown and a moderate amount. My assessment is that the pain could be from gas in his stomach because the ostomy bag has been filling up with gas. 
R: I recommend that this patient is given a medication to prevent further gas accumulation in his bowels that could be the source of his pain. Continue on antibiotics to prevent infection and further complications.

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