CM addendum - Concept Map Level 4 Student name _Dannette...

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Concept Map Level 4 Student name __ Dannette Dietz _________________________date(s) of care __ Shift report: 3/8/06: C.G. is a 67yr old Caucasian female admitted 3/6/06 through the ER. Dx of vomiting, Hyponatremia and prerenal azotemia. Medical hx of CAD, MI x5, DM type 2, PVD, HTN and cholecystectomy. Allergic to codeine, full code status, IV (L) hand NS 75ml/hr, full liquid diet, BRP w/assist, I&O q shift, LBM 3/4/06, nurse aide reported BP of 63/45 w/dinamap. Primary nurse and I both took a manual BP of 118/64. 3/9/09: 1800 ADA diet, saline lock (L) arm, night shift nurse withheld Toprol b/c BP was 107/48, LBM 3/8/06 diarrhea in the evening. History of present illness: C.G. presented to the ER with 1-week malaise, general abdominal pain, nausea and vomiting. ER lab reported leukocytosis. IV zofran was administered, but did not control the nausea and vomiting. Pt was admitted. Assessment System Findings- include assessment, labs and dx tests Pathology explanation Nursing implications- include medications and teaching Neuro Sensory function – WNL Motor function – WNL No seizure or tremors No assessment changes 2 nd day WNL Continue to assess and monitor q shift and prn for mental status changes or other neuro changes. Cardiac Hx of CAD, PVD, HTN, MI x5 T: 98.2 BP: 118/64 P: 71 T: 98.8 BP: 111/46 P: 71 Apical pulse: 78, 3/9/06: 84 Radial and dorsalis pedal pulses: weak, regular (L) foot: anterior localized edema, 1+ nonpitting BUN 24mg/dl (normal 10-20mg/dl) indicates hypovolemia, dehydration, CHF, MI, renal disease RBC 3.20 (normal female: 4.2-5.4) indicates anemia, dietary deficiency and renal failure Hgb 9.5g/dl (normal female 12-16g/dl) indicates anemia, dietary deficiency, kidney disease Hct 27.4% (normal female 37-47%) indicates anemia, dietary deficiency K+ WNL No other assessment changes 2 nd day Coronary artery disease – atherosclerosis is major cause of CAD, the vessel lumen narrows and restricts blood flow and inadequate oxygenation of myocardial tissues occur – this can cause decreased peripheral pulses. Myocardial infarction – myocardial tissue is severely deprived of O2 and ischemia develops which can lead to necrosis of the tissues. PVD – arterial occlusion deprives the lower extremities of O2 and nutrients – this can cause decreased pedal pulses. Encourage pt to maintain a minimum fluid intake of 1500ml/day (7a-3p 600ml / 3p-11p 600ml / 11p-7a 300ml) Consult MD if pt is on diuretics and experiences significant weight loss (>2lb/day or 5lb/wk), weigh pt daily. Place pt in semi- to high Fowlers position to decrease cardiac workload. Instruct pt to avoid straining
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This note was uploaded on 12/11/2011 for the course NA 123 taught by Professor Na during the Spring '10 term at Abraham Baldwin Agricultural College.

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CM addendum - Concept Map Level 4 Student name _Dannette...

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