Concept Map 1 (clinical shift on 2/14/19) by Lauren Ott

Medical Diagnosis & Patient Gender & Age

lauren_ott29 — 2019-02-22 00:05:49 UTC

-63 y/o female
-Malignant neoplasm of the ovary
-P/t is post op day 0 from lymph node removal surgery with partial Vaginectomy and hernia repair
-Complication during surgery (main artery supply to left leg was accidentally clipped during surgery causing surgeons to have to stop the blood supply to left leg for 3 hours while artery was being repaired)

Medications

lauren_ott29 — 2019-02-22 00:09:03 UTC

Tylenol:
1000 mg PO q4 hr (given at 0900 & 1300)
1) important to have pt know the max daily dosage (4000 mg) to avoid liver toxicity
2) intended to relieve mild to moderate pain
Ketorolac:
15 mg IV q6 hr (given at 1300)
1) important for pt to be careful when moving/getting out of bed because it can cause dizziness
2) intended to relieve and manage short term pain/inflammation
Heparin:
5000 units subcut q8 hr (given at 1400)
1) important for pt to be careful and monitor for s/s of bleeding and bruising
2) intended to prevent blood clot formation
Zofran:
4 mg IV PRN (given at 0930)
1) important for pt to be careful when moving/getting out of bed because it can cause dizziness
2) intended to prevent post op nausea/vomiting
Oxycodone:
5 mg PO PRN (given at 1400)
1) important to have pt to let nurse know if any difficulty breathing and keep up with stool softeners
2) intended to reduce moderate to severe pain

Signs & Symptoms

lauren_ott29 — 2019-02-22 01:24:33 UTC

S: nausea/dizziness when trying to ambulate, anxiety about walking post surgery, pt had dizziness/nausea right before & after ambulating, difficulty with deep breathing prior to use of spirometer, not passing gas
O: VS (most recent) - temp 36.6, pulse 72, resp 20 on RA, 90% SpO2, BP 116/45, pain score is 5 out of 10 and decreased to a 3 by end of shift
-p/t is on VS q4 hr
-intake for day is 1940 mL and output is 415 mL
-urine is tea color and clear
-Pedal pulses are heard with doppler, cap refill <2 seconds, no s/s of 5 P's (pallor, pain, pulse, paralysis, and paraesthesia)
PMH: hypertension, fibromyalgia, rheumatoid arthritis, stroke (cerebrovascular accident)

Monitoring

lauren_ott29 — 2019-02-22 02:16:46 UTC

1) VS ordered q4 hr
-Most recent VS were temp 36.6, pulse 72, resp 20 on RA, 90% SpO2, BP 116/45, pain score is 5 out of 10
-VS baseline for pt is temp 36.6, pulse 78, resp 16 on RA, 94% SpO2, BP 118/52
-trended all past vital signs in p/t chart via VS graph and all vitals were steady with no significant changes
2) Doppler pulse assessment ordered 2/14/19 Q1 (later changed to Q4) to assess if pedal pulses are present post surgery complication - pulses were heard and +2 every doppler reading
3) Collaboration with surgical resident who came to assess patient's pulses and changed our pedal assessments to Q4 for the doppler readings
4) Most recent lab tests were done on 2/14/19 - all tests were within normal range except for:
-creatinine kinase from 2/14/19 was 321 U/L which is higher than normal range indicating possible muscle injury or damage
-creatinine kinase from 2/13/19 was higher than from 2/14/19 at 412 U/L showing patient is progressing in a positive direction

Assessment Findings

lauren_ott29 — 2019-02-22 02:25:49 UTC

-Lung/heart sounds WDL
-Deep breathing was more difficult for pt prior to use of spirometer
-Pedal pulses were strong and heard with doppler
-A&O x 3
-Cap refill was <2 seconds
-Assessed for compartment syndrome throughout shift and no s/s of 5 P's (pallor, pain, pulse, paralysis, and paraesthesia)
-P/t has anxiety concerning the surgical complications and has fear/anxiety with ambulating
-Pt had dizziness/nausea right before & after ambulating (taking breaks helped with nausea)
-Pain score of 5 out of 10 throughout shift but was lowering to a 3 by the end of shift

Nursing Diagnosis 2

lauren_ott29 — 2019-02-22 03:06:38 UTC

Anxiety r/t surgical complication m/b expressed concern with current health condition and fear of ambulating

Nursing Diagnosis 1

lauren_ott29 — 2019-02-22 03:10:10 UTC

Risk for falls r/t postoperative recovery period, anxiety, and decrease in lower extremity function m/b nausea and dizziness before/after ambulation and expressed anxiety about ambulation

PC 1

lauren_ott29 — 2019-02-22 03:37:26 UTC

Pneumonia
-this is related to the pt being a post operative surgical patient with difficulty deep breathing
-trying to prevent through deep breathing exercises, incentive spirometer, assessing VS/respiratory status, and ambulation

PC 2

lauren_ott29 — 2019-02-22 03:37:36 UTC

DVT
-this is related to the pt having a surgical complication involving the compromised blood flow to lower left extremity during surgery
-trying to prevent DVT through assessing pulses with doppler, heparin medication, ambulation, and SCDs

Patient Goals

lauren_ott29 — 2019-02-22 03:50:03 UTC

-Patient will identify and vocalize any concerns and areas of stress/anxiety with health care team to help reduce stressors
-Patient will demonstrate techniques to help control anxiety and use support system as a resource

Patient Teaching

lauren_ott29 — 2019-02-22 03:50:09 UTC

-Teach the patient and family about the signs and symptoms of anxiety
-Provide community resources to the family and patient for at home to help control and reduce anxiety levels post discharge

Nursing Interventions

lauren_ott29 — 2019-02-22 03:50:19 UTC

-The nurse will assess p/t's level of anxiety and provide a stress reducing environment for the patient to aid in reducing anxiety and stress around the care situation
-The nurse will encourage the patient to talk about feelings, concerns, uncertainties, and fears with the nurse and/or a support system

Patient Goals

lauren_ott29 — 2019-02-22 03:52:49 UTC

-Patient will explain methods to prevent injury prior ambulation
-Patient will demonstrate techniques to help control anxiety and vocalize concerns to decrease stress revolving around ambulating

Nursing Interventions

lauren_ott29 — 2019-02-22 03:52:57 UTC

-The nurse will monitor and record the patient’s ability to tolerate the activity/exercise and the use of the patient's extremities
-The nurse will carefully assist the patient while ambulating to ensure pt safety

Patient Teaching

lauren_ott29 — 2019-02-22 03:53:19 UTC

-Educate the patient on the correct use of the needed assistive devices (podium) to help aid the patient in ambulation and mobility
-Provide patient with methods to decrease dizziness such as getting up slowly and taking breaks between movements