Concept Map Template NURS 3073

Student Name:

Client: 65A Age: 19 DOA: September 19th Code status: Full code Allergies: NKA
Reason for hospitalization: Staph Aureus Sepsis, endocarditis
Priority assessments: circulatory, respiratory, skin, GI
Significant history: IV drug use, anxiety, depression, dental abscess

Nursing diagnosis: Risk for altered tissue perfusion related to valvular septic emboli secondary to endocarditis

Supporting data vegetation to tricuspid valve (septic emboli), endocarditis, pleuritic chest pain, +2 edema to feet, +3
edema to ankles, +4 edema to legs, dysrhythmias, reduced supply of oxygen, irregular breathing, Hgb 80

Goals: Patient will achieve and maintain adequate tissue perfusion to all body systems.

Interventions
-Observe for sudden SOB, tachypnea, pallor or cyanosis
-Monitor for patient chest pain, tachycardia and hypotension
-Auscultate heart sounds for changes in murmur
-Monitor edema to legs
-Observe for decreased peripheral pulses, pallor, coldness, cyanosis.
-Observe urine for hematuria
-Administer antimicrobials as ordered

Outcomes
________________________________________________________________________________________
Nursing diagnosis Impaired Gas Exchange related to airspace disease

Supporting data airspace disease to bilateral lungs, left pleural effusion, pleuritic chest pain, decreased air entry to left
lower lobe, ++ drowsy, SOBOE, Hgb: 80, diaphoresis, order for 2lpm nasal cannula

Goals Patient will demonstrate improved ventilation and adequate oxygenation of tissues

Interventions

-Monitor and record vital signs

- Monitor respiratory rate, depth and rhythm
- Assess pt’s general condition
- Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
- Elevate head of the pt.
- Note for presence of cyanosis
-Encourage frequent position changes and deep-breathing exercises
-Provide supplemental oxygen 2plm nasal cannula

Outcomes
_________________________________________________________
Nursing diagnosis Risk for Infection related to inhibition of antibodies secondary to immunological system
action

Supporting data: Staph aureus sepsis, endocarditis, predisposition to bacteremia (endocarditis), septic emboli, saline
lock, nosocomial infection, order for cefazolin, suprainfection

Goals Patient will be free of infection, afebrile, with no over symptoms of infection or infective process noted.

Interventions
-Monitor temperature q4h
-Monitor for signs and symptoms of deterioration
-Observe for symptoms of suprainfections such as white plaque in mouth and irritation to vagina
- inspect wounds, IV sites, catheter sites, invasive devices and lines, changes in drainage or body fluids
-administer antibiotics as ordered

Other:
-acute pain (tolerance for hydromorphone)
-ineffective coping (IV drug user, homeless)
Outcomes
___________________________________________________________
Diagnostics/lab data (Identify data most relevant to interventions/diagnosis above)
Creatinine: 31
CRP: 310.0  (<=5.0mg/L)
LDH: 225 (135-214)
ERC: 2.81 (3.71-5.49)
Hgb: 80
HCT: 0.238 (0.36-0.49)
MPV: 7.2  (7.6-10.9)
______________________________________________________________________
Medications (Identify all meds. Note meds relevant to priority nursing diagnoses & those required for overall management)

Methadone liquid 60mg PO q24h

-Class: opioid analgesic
-Indications: Pain in patients with opioid tolerance, detoxification and maintenance therapy for opioid use
disorder
-Action: binds to opiate receptors in the CNS (decrease in pain and withdrawal symptoms)
-onset: 30-60min, peak: 90-120, duration: 4-12hr
-Adverse reaction: confusion, sedation, hypotension, constipation

Magic Mouthwash 15mL TID

-diphenhydramine, viscous lidocaine, antacid, nystatin, and corticosteroids
-prevent thrush?

Enoxaparin injection 40mg SC q24hr (prophylaxis)

-Class: anticoagulants, antithrombotic, low molecular weight heparin
-Mechanism of action: prevention of thrombus formation, potentiates the inhibitory effect of antithrombin on
factor Xa and thrombin
-Indication: prevention of DVT or PE, treatment of DVT with or without PE
-Normal dosage: 40mg UID
-Side effects: bleeding, anemia

Polyethylene glycol 3350 powder – 17g, PO, q12h

-Class: laxatives, osmotics
-Mechanism of action: acts as an osmotic agent, drawing water into the lumen of GI tract
-Indication: treatment of occasional constipation
-Side effects: urticarial, abdominal bloating, cramping, flatulence, nausea

Cefazolin 2g in NaCl 0.9% 100mL – 2g, IV, q8h (2200)

-Class: anti-infective, first generation cephalosporins
-Mechanism of action: binds to bacterial cell wall, causing cell death
-Indication: Endocarditis, sepsis
-Side effects: diarrhea, n/v, rash, phlebitis
-Onset: rapid, peak 0.5-2hr, duration 6-12hr

Ibuprofen 400mg PO q4h, PRN pain

-Class: NSAID
-Indication: pain
-Action: inhibits prostaglandin synthesis
-onset: 30min, 2-4, 6-8hr
-Side effects: headache, constipation, dyspepsia, n/v,
-normal dose: not to exceed 1200mg/day

Sennosides 8.6mg PO, bedtime, PRN constipation

-Class: laxative
-Mechanism of action: alter water and electrolyte transport in the large intestine, resulting in accumulation of
water and increased peristalsis
-Indication: constipation
-Side effects: cramping, diarrhea

Nicotine 1mg/spray 1spray, q1h, PO, PRN nicotine craving, remove patch at 21:05
-Class: smoking deterrents
-provides source of nicotine during withdrawal

Ondansetron injection 4mg IV q6h PRN N/V

-Class: antiemetics
-Indication: prevention of nausea and vomiting
-Mechanism of action: blocks the effects of serotonin at 5-HT3-receptor sires (selective antagonist) located in
vagal nerve terminals and the chemoreceptor trigger zone in the CNS
-Side effects: headache, constipation, diarrhea
-Onset: rapid, peak 15-30

Venlafaxine XR 3.75mg PO daily

-Class: antidepressant, antianxiety, SSNRIs
-Indications: MDD, GAD
-Inhibits serotonin and norepinephrine reuptake in the CNS
-Onset: within 2 weeks
-Side effects: dizziness, headaches, insomnia, weakness

Zoplicone 15mg PO bedtime, PRN sleep

-Class: sedative, cyclopyrrolones
-Mechanism of action: interacts with GABA-receptor complexes
-Indication: short term management of insomnia
-Side effects: bitter taste
-Onset: rapid

Acetominophen 975mg PO q6h (1800)

-Class: antipyretic, nonopioid analgesic
-Mechanism of action: inhibits synthesis of prostaglandins that serve as mediators of pain and fever
-Indication: mild pain, fever
-Side effects: nausea
-Onset: 0.5-1hr