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Med/Surg Concept Map COPD Arthur Moll Ocean County College 12/12/2008 Arthur Moll Care Map Med/Surg 2/1/2009
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Nursing DX: Imbalanced Nutrition: less than body requirements related to SOB and reduced energy to eat; also poor dietary choices and high blood glucose levels as noted from BG monitoring. Diabetic ADA 2000 Kcal –2g sodium diet –Does not like the hospital food; doesn't eat all that is on his tray each meal. –Has asked dietary for a hamburger, Says, "All I want is a hamburger." #2 Nutrition Medical Diagnosis: Exacerbation of Chronic Obstructive Pulmonary Disease - Dyspnea secondary to primary lung disease, CHF, anemia, anxiety. Commorbid Conditions: History of Prostate enlargement History of Hypertension History of Hyperlipidemia IV Site: Saline lock left forearm 22 guage. No signs of infection or infiltration from saline flushes. Pain Level: 0 throughout shift Nursing DX: Risk for Constipation related to decreased physical activity and inadequate nutritional intake. –Dietary history of insufficient fiber and fluid intake (pt self reported). –Abdomen soft and flat –Bowel movement (medium) in morning formed and soft. –Docusate Sodium (Colace) 100mg PO BID –Pantoprazole (Protonix) 40mg PO daily start tomorrow. #6 GI Nursing DX: Imbalanced Nutrition: less then body requirememnts related to insufficient insulin production evidenced by random blood glucose checks. –Blood sugar before meal 7am (162) 2 units given. –Blood sugar before meal 12pm (156) 2 units given. –Insulin Aspart (Novolog) scale. #5 Endocrine Nursing DX: Spiritual Distress related to chronic illness, limited physical mobility and decreased social interaction manifested by thoughts he will only live another 6 months. –Patient stated that he knows how this disease goes and will only be around about 6 more months. –Expresses a lack of meaning and hope for his life that results in him getting depressed. –Zolpidem (Ambien) 5mg x2 po daily at bedtime prn for sleep. #4 Psyche Nursing DX: Impaired Skin Integrity related to decreased tissue perfusion evidenced by stage 1 decubitus ulcer at sacral apex. –Low risk for skin injury. –Current stage 1 sacral apex with clean Tegaderm dressing intact. Area not red or swollen, no exudate, no pain reported. –Continent bladder and bowel. –Skin warm and dry, no signs of cyanosis –Eccymosis of abdomen, 2.5 inch band from right to left side inferior to umbilicus from heparin inj. Break in skin integrity at site bandage covering. –Skin turgor good –Bactroban 2% oint apply sacral area TID #7 Skin Nursing DX: Decreased cardiac output related to hypertension evidenced by SOB and tachycardia with minor exertion. –BP 118/65 (800) –BP 122/70 (1200) –P Peripheral (800) while in bed 84 +2 bilaterally upper and lower extremities rythm regular.
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