Week 3 Concept Map by Chantel Miles https://padlet.com/chantel_miles/week3conceptmap Hampton University Nurv 346 April 18, 2018 en-us 2018-04-19 02:21:54 UTC 2018-04-19 03:15:23 UTC hello@padlet.com Patient Info chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253257780 E.B.
Female
12/17/1934
84 yo
Retired Deli Manager
Full Code

Allergies:  Lidocaine, Percocet, Procaine]]> 2018-04-19 02:24:22 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253257780 Vital signs and Labs chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253258399 Vitals @ 0733: BP 133/71, P 55, Temp 96.7, Resp 18 and O2 96% via RA
B/S: @0800: 112
Labs: RBC 3.71, Hgb 11.5, GFR 56.0, Alb 3.1, HgbA1c 6.6, BUN 22, Cr 0.9]]> 2018-04-19 02:28:16 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253258399 Priority RN Diagnosis chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253259083
  • Excess Fluid Volume
  • Risk for Decreased Cardiac Output
  • Risk for Imbalanced Nutrition: Less Than Body Requirements
  • Risk for Infection
  • Risk for Deficient Fluid Volume

    • ]]>     2018-04-19 02:32:28 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253259083     Procedures and Results chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253259978 EB had a Ultrasound of the retroperitneum on 4/16/2018. As a result the findings were Rt side 10.2 cm and Lt side 10.1 cm with normal echotexture and no abnormalities present. ]]> 2018-04-19 02:39:01 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253259978 Medications chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253260537 Tylenol 650mg (prn)
    senna-ducosate 8.6-50mg 1 tab
    triamcinolone actinide 5% topical cream 
    Tricor 48mg
    Lispro 1-6u
    ASA 81mg
    Metroprolol 50mg]]>     2018-04-19 02:42:37 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253260537     System Assessment chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253261135 General Upon arrival Pt was clean, neat and well groomed. Calm and pleasant manner. communicate clearly. Hearing and vision normal.
    Neuro     A/o*4,PEERLA: 3mm, round, brisk response, able to focus, EOM- together and smoothly, able to follow commands, Muscle grips- upper extremities equal grip and lower extremities push/pull equal. sensory intact.
    Respiratory     Symmetrical chest rise and fall, clear lung sounds, eupnea, RA
    CV     No JVD present, No PMI visible, S1 and S2 sounds normal, apical rate 62 with regular pattern, 2+ perphial pulse, cap refill less than 3 in upper and lower extremities.
    GI     Abd round, nontender, no masses. normoactive bowel sounds. cardiac diet and at breakfast patient ate 75% with 240mL
    GU     Purewick in place for incontinent episodes. WNL female genitalia, no redness, skin intact, urine yellow and clear.
    Integ     Small scabs d/t scratching from hives on shoulders and sacral area
    MS     WNL active, full ROM, erect posture and steady gait
    Pain     Pt reports no pain; 0 on 0-10 scale]]>     2018-04-19 02:45:54 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253261135     Diagnosis and Medical History chantel_miles https://padlet.com/chantel_miles/week3conceptmap/wish/253261198 Pt diagnosis
    Patient Admission on 4/14/2018 presented with hypoglycemia manifestations d/t nausea and vomiting for 4 days and SOB d/t hives reaction present on back and arms. Pt had loss 14 lbs within weeks time. Creatinine level 2.0, K+ 2.8, BUN 71. Patient was prescribed a PO steroid for 5 days. Final diagnosis is AKI with diarrhea.
    Medical History
    DM, Rt and Lt knee osteoarthritis, HTN]]>     2018-04-19 02:46:13 UTC https://padlet.com/chantel_miles/week3conceptmap/wish/253261198