Concept Map Nursing free essay sample

Diverticulitis, is characterized by inflamed diverticuli and increased luminal pressures that cause erosion of the bowel wall and thus microscopic or macroscopic perforation into the peritoneum. A localized abscess develops when the body is able to wall off the area of perforation (Lewis, 2011, pp. 1022-1029). Hydronephrosis describes the situation where the urine collecting system of the kidney is dilated. This may be a normal variant or it may be due to an underlying illness or medical condition (Lewis, 2011, pp. 1022-1029). Diagnostic Tests and Procedures: On February 16, 2013 an abdominal x-ray with a small bowel through was done with contrast. February 11, 2013 a cysto right stent retrograde pyleogram was done in order to unblock a stone. CBC and blood cultures were drawn. Stool OB and UA were ordered as well. Medical Management: Patient was seen by an E. R. doctor who decided not to start her on any antibiotics. Patient has been on 2 courses of Ciprofloxacin and Flagyl prior to admission. We will write a custom essay sample on Concept Map Nursing or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page Blood work was drawn and abdominal x-ray ordered. Intravenous fluids were initiated in the emergency room to hydrate her as well to help the nausea. Urology consult was called for the patient. A stool study was also ordered down in the emergency room. She has had diarrhea for the past few days prior to admission. Clostridium difficile is a consideration due to the use of Cipro twice in the month of January. Zofran was ordered for her nausea, fluid hydration to correct her hydration status, and potassium. Current Medications: Simvistatin 20 mg PO for high cholesterol: report dizziness, insomnia, abdominal cramping, muscle pain. Obtain liver function test, Alk phosphate, Ck levels. Xalantan 0. 005% eye drops to both eyes for prostaglandin antagonist: report hypotension. Pyridium 100 mg PO for urinary analgesia: report headache, vertigo and expect bright orange urine. Bactrim Ds 1 tablet PO for infection: report erythema, short of breath, fever and fatigue. Levothroid 0. 088 mg PO for thyroid supplement: report tachycardia and advise to drink with water. Protonix 40 mg PO for decrease acid secretion: report abdominal pain, hyperglycemia, diarrhea, and headache. Make sure liver function tests are monitored. Developmental Stage: B. S. is 81 year old Caucasian female this puts her in the stage of integrity vs. despair. The client has achieved integrity. Client is happily married, has 2 children and 5 grandchildren. She is a retired schoolteacher where she worked for 32 years in the city of Pasadena. She has travelled to numerous countries and states with her husband. They own their own home and live comfortably. Psychosocial: Client is happily married for over 50 years and has 2 children with 5 grandkids. She has been retired over 30 years and worked as a schoolteacher. She does have some concern with help at home once she is discharged due to her and her husband being elderly. She expressed concern with cooking and cleaning. As far as financially client states she and her husband are stable and that they saved up for their retirement. Discharge Planning: The patient should eat a well balanced, healthy diet. It is important that they get enough calories, protein, and essential nutrients from a variety of food groups. The patient needs to eat smaller meals, and eat more often and need to drink plenty of liquids. The doctor may prescribe drugs that will help relieve the patients symptoms such as anti-diarrhea drugs, fiber supplements, and pain medications. To help manage the patients Crohns disease is to join a support group and exercise. Also trying biofeedback to reduce muscle tension, deep breathing exercises, listening to music, and other ways to relax. Neurological Assessment: patient is awake and alert times 4. Denies head injury, seizures or seizure disorder, paralysis, or abnormalities of sensation and gait coordination. Denies syncope dizziness, vertigo, memory loss, speech coordination, frequent headaches, or tremors. Denies problems with speaking. Cardiovascular Assessment: No visible pulsations, no heaves or lifts. Apical pulse present in the fifth intercostal space at the left midclavicular line. Auscultation of apical rate 62 beats per minute, normal rhythm regular S1 S2 heart sounds present. Pulsations present when supine and disappear at a 45 degree angle position. Extremities are brown color without redness, cyanosis, lesions or varicosities bilaterally. Temperature warm bilaterally, Allen test was negative. Homan’s sign negative. Carotids: +2 and present bilaterally. Right Radial +2, left radial +1 , Right Brachial: +2 left brachial +1 Femoral: +2 and present bilaterally. Popliteals: +2 and present bilaterally. Lung Assessment: No abnormal lung sounds noted upon auscultation to both lung fields. Regular, relaxed even respirations. Palpation of chest wall without tenderness. Percussion is resonant to percussion over lung fields. Auscultation of vesicular clear sounds over lung fields, no adventitious sounds present. Voice sounds with in normal limits. Integumentary Assessment: No macules present or sores/ulcerations noted. Hair is light brown in color and thin in texture. Nails are round, symmetrical, even in texture. Bilateral hands appear normal. Capillary refill is less than 3 second. Skin is warm and dry to touch. Gastrointestinal Assessment: Bowel sounds present and hyperactive sounds auscultated in all four quadrants. No bruits or vascular sounds present. Tympanic sounds percussed in all four quadrants. Palpation abdomen soft with no tenderness, or organomegaly palpated. No masses visible or palpated. Patient does complain of frequent loose stools. Gentourinary Assessment: No odor or swelling noted as stated by patient. Urine yellow in color. Client voids independently with minimal assist to the bathroom. Endocrine assessment: No enlargement of pancreas noted. Skin is warm and dry to touch. Heart sounds within normal. Vital Signs: Temperature: 97. 0, blood pressure 105/64, pulse 60, respiration 18, pain level of 7/10 and O2 saturation of 98% on room air. Patient Education: Teach the client that a high fiber diet, mainly from fruits and vegetables, and decreased intake of fat and red meat are recommended for preventing diverticular disease. Weight reduction is important for the obese person. Increased intraabdominal pressure should be avoided because it may precipitate an attack. Avoid straining during bowel movements, vomiting, bending, lifting and tight restrictive clothing. In acute diverticulitis, the goal of treatment is to let the colon rest and the inflammation subside (8th edition, Potter and Perry, Fundamentals of Nursing). Nursing Diagnosis #1: Extracellular fluid imbalances related to GI losses such as vomiting and diarrhea as evidenced by abdominal pain and decrease urine output. Goal: Patient will report taking in a fluid intake of 800 mL by the end of shift. Intervention: Offer fluids hourly and avoid cold fluids. Evaluation: Goal was met.