Care Map EW 11-3 - Concept Care Map Student Name Semia McFadden Key Problem 1 Ineffective tissue perfusion R\/T interrupted blood flow(edema at operative

Care Map EW 11-3 - Concept Care Map Student Name Semia...

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Concept Care Map Student Name: Semia McFadden Client Initials: EW Clinical Dates: November 3, 2015 Demographics: 13 yo Caucasian female Blood type: O Positive Wt. 52.8 Kg Ht. 158.5 cm Allergies: NKDA Diet: NPO/ ice chips Full Code Last BM: --- Diagnosis: S/P Spinal Fusion from T2-L1 Vital Signs: 1200 1600 BP 92/57 111/63 T 37.4 38.5 P 96 73 R 15 17 O2 99% 97% Pain 10/10 7/10 Medical Hx: Idiopathic Scoliosis of thoracic region – left side Attention Deficit Disorder Medications: See Med Sheet Abnormal Labs See Lab Sheet Key Assessments: Vital Signs JP Drain Respiratory Pain Key Problem # 1 Ineffective tissue perfusion R/T interrupted blood flow (edema at operative site) AEB decreased ROM and muscle strength. Data: ROM & muscle strength ↓ Hgb levels (8.5mg - 11/2 @1405) Compromised skin integrity JP Drain Surgical incision 2 IV- R&L hand TX: Proper hand washing, increase fluids, administer meds, Turn Q2 Meds: Acetaminophen Key Problem # 3 Acute pain R/T surgical manipulation AEB reports of pain and restlessness Data: Report of 10/10 on pain scale @ 1410 Crying/ restlessness Telling friends she doesn’t feel better Surgical procedure Spinal fusion on 11/2/15 T (38.5) & BP (111/63) ↓ O2 sat (97%) TX: Instruct non-pharmological methods Provide pain meds in a timely manner Instruct on use of PCA pump Meds: PCA – morphine, Diazepam, Acetaminophen How do they relate? 1→ 3 Ineffective tissue perfusion leads to acute pain 1↔ 2 Ineffective tissue perfusion leads to impaired skin integrity 2→3 Impaired skin integrity leads to acute pain Key Problem # 2 Impaired skin integrity R/T surgical procedure Data: Nutritional status – NPO / ice chips Braden scale of 17 2 facial lesions Immobility/ bedrest Compromised skin integrity JP Drain Surgical incision 2 IV- R&L hand TX: Turn Q2 Meds: Clindamycin
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Concept Care Map Problem #1: Ineffective tissue perfusion R/T interrupted blood flow (edema at operative site) AEB decreased ROM and muscle strength. General Goal: Demonstrate normal sensations and movement as appropriate Expected Outcome: Patient will maintain adequate tissue perfusion during my shift from 12 to 6 AEB BP within normal range for patient, usual mental status, and palpable peripheral pulses.
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  • Fall '15
  • Brown
  • Ineffective Tissue Perfusion, Concept Care Map

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