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Concept Map # 2

Josip Benko Fundamentals of Nursing Andrews University November 10, 2011

Introduction
Situation and Background: ! 39 year old Caucasian male came in to ER with nausea, vomiting and Leukocytosis affecting patients previous right hip surgery. Social History:
! He is divorced and has family issues about which nursing home to put his father in. Loves RC racing cars and magazines. He currently works for a trailer company.

Past Medical/Surgical History: ! Chronic right hip pain, total hip arthroplasty (10-27-11), infection removed by extended trochanteric osteotomy

Nursing Assessment
Assessment: ! Patient has infection in previous right hip surgery ! Is not weight bearing on right leg ! Patient denies any pain. ! Patient is suffering from depression due to personal family matters. ! Patient is also a type 1 diabetic and does not properly monitor glucose levels ! Patient has stated suicidal comments ! Patient is taking prescribed antibiotics History of present illness: ! Diabetes Mellitus Type 1, Chills, Infection Medical diagnosis (es): ! Nausea, Vomiting, Leukocytosis

Nursing Diagnosis #1
! Impaired physical mobility
Nursing diagnosis

Related to [etiology]

! Restrictions of movement, including mechanical and medical protocol

As evidenced by [defined characteristics]

! Inability to move purposefully within physical environment, reluctant to attempt movement, use of walker, hip surgery 10-27-11, nonweight bearing on right leg

Goals and Outcomes #1


Intervention: The nurse will assess ability to perform ROM to all joints.

Intervention: The nurse will provide positive reinforcement during activity.

Goal: The patient will ambulate from the bed 10 feet to the chair by the end of the shift using the walker.

Intervention: The nurse will obtain appropriate assistive device.

Intervention: The nurse will encourage and facilitate early ambulation when possible.

Goals and Outcomes #1 cont.


Rationale: Provides data for the nurse to evaluate how much patient is able to move

Rationale: Patient may be reluctant to move and a positive approach allows the learner to feel good about the activity.

Outcome: At first patient reluctant to ambulate to chair so implemented other interventions to maintain patient active. 45minutes before the end of the shift patient finally decided to ambulate the 10 feet to the chair.

Rationale: Assistance device helps to enhance mobility especially if a patient is nonweight bearing

Rationale: Early mobility promotes confidence and reduce the chance that debilitation will occur.

Goals and Outcomes #2


Intervention: The nurse will provide a safe environment: bed rails up, bed in down position.

Intervention: The nurse will instruct the patient regarding the need to make the home environment safe

Goal: The patient will not sustain a fall by the end of the shift.

Intervention: The nurse will place items used by the patient in easy reach, such as call light, urinal, walker, and telephone.

Intervention: The nurse will educate patient about potential risk factors for falls.

Goals and Outcomes #2 cont.


Rationale: These measures promote a safe secure environment and may reduce risk for falls

Rationale: A safe environment will help prevent injury related to falls.

Outcome: Patient did not sustain a fall. However, future teaching is required because patient applied light pressure on right leg which is non-weight bearing.

Rationale: Stretching to get items form bedside table that are out of reach can disrupt the patients balance and contribute to falls.

Rationale: Teaching patient will help inform patient to prevent easy to fix hazards that could lead to falls.

Nursing Diagnosis #2
Nursing diagnosis

Risk For Unstable Blood Glucose Levels

Related to [etiology]

! Insulin deficiency with inability to utilize nutrients

As evidenced by [defined characteristics]

! Type 1 diabetes, hyperglycemia

Goals and Outcomes #1


Goal: Patient will maintain blood glucose levels within 70 100mg/ dL by the end of shift.

Intervention: The nurse will assess sings for hyperglycemia.

Intervention: The nurse will monitor blood glucose levels AC and HS.

Intervention: The nurse will follow diabetic diet of 1800 kcal/day.

Intervention: The nurse will teach about importance of maintaining proper diet.

Goals and Outcomes #1 cont.

Outcome: Patients glucose level was 65 mg/dL. Glucose levels lowered then normal which is within 70-100mg/dL. Potential reason is that patient is stressed about family issues and refuses to eat enough food to maintain glucose levels.

Rationale: Hyperglycemia results when inadequate insulin is present to use glucose. Excess glucose in the bloodstream creates an osmotic effect that results in increase thirst, increased hunger and restlessness.

Rationale: Monitoring glucose levels before breakfast and bed time can help provide data to see how much patient fluctuates in glucose levels.

Rationale: Following a specific diet provided by a dietician will help maintain adequate glucose levels.

Rationale: In teaching the patient about maintaining a proper diet will help maintain safe glucose levels when patient goes home.

Goals and Outcomes #2


Intervention: The nurse will assess patients current knowledge of type 1 diabetes Intervention: The nurse will provide a quite, calm atmosphere without many interruptions. Intervention: The nurse will teach patient about different types of insulin and the importance of rotating injection sites.

Goal: Patient will verbalize correct information about type 1 diabetes and treatment by the end of shift.

Intervention: The nurse will pace the instruction and keep sessions short.

Goals and Outcomes #2 cont.


Rationale: Patient teaching begins with what the patient already know about the disease and its treatments.

Rationale: A calm quiet environment assists the patient with concentrating more completely and decreases stress. Rationale: understanding the different types of insulin and injection sites will help decrease potential of hyperand hypo- glycemia and insulimia. Rotating sites decreases the chance of skin breakdown.

Outcome: Patient was not first interested, but by the end of the shift patient was able to verbalize learned material correctly.

Rationale: Learning requires energy, so shorter, well-paced sessions reduce stress and fatigue on the patient.

Barriers
Barrier: Patient is uncooperative Barrier: Patient is depressed Goal Interference: patient is not interested in learning fall precaution Barrier: Patient does not eat recommende d calories Goal Interference: Being able to maintain glucose level of 70 100mg/dL
Barrier: Patient not interested in learning

Goal Interference: Prevents from ambulating

Goal Interference: Information may be difficult to teach.

Linkages
Prolonged bed rest

Not enough calories (protein + carbohydrates)

Decreases wound healing

May increase Stress

Ambulating

Promotes blood flow that helps with wound healing

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