CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
BE BLOOD
HypoVOLEMSHOCKCHARNEEMED
ASCIS
REDoctorOF
VOLUME. BL EDEMA DEFlyDRATow
By
INFRAVASCOLA CAN CAUSE Loss ,
, ,
VOSELERIE EmPALErnsly OX EN THE BOS .
·FLulD OX REDUCTIO
OF LESS O2 AND Nutrients To OTHER Organ
AND
Of BLOOD ,
REDUCTION Blood Cassels To MAINTEN BP
CONSTRICTIng
= .
COMPENSATE By
DE
ATTEMPT TO
BODY
Fallae , KIDLEY, Liver, Brain , THEN
=
LEADS To Organ
BLOOD Volume
HypoperFustor & FAILURE -
Low
ProLargeD
-
ORGAN
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL
(REASON FOR TEST AND RESULTS) -
PT S C
.
.
Admitted March 18 202 K
, FINDINGS
· BLOOD TESTS - MALE, 52 Y/0 -
ACTIVIT INTOLRANCE
CBC
CREATINIME DISTENDED
-
BON & ABDOWIn is
POOR SKIN TORGOR
-
-
& Hemoglobin
-
Hematocriti
-
Poor SKIN TURGOR
DAN
-
· URIKE TESTS -
Dry MucouS
MEMBRANES -
ABDOMINAL
-FLUID Los GRAVITY HAS NOT URINATED
SINCE YESTERDAY
- FAT IGLE
-
VITAL Stans Monitoring
·
WEAK"
HAS Loo BP
"FEEL DIZZy
Hypovoluehig
=
Vomit FUG
....
:
ANDM HR -
ORTHOSTATIC VITALs
A DEMEROL ALLERGY
·
LAySy , SITTEN2 STAND
, -
RASH
· IMAREng TEST
ORgANSTATUS
GETS A
·
URSORNDS :
Monitor HEART
.
-
ECG -
ANTICIPATED NURSING INTERVENTIONS
Moniton VITAL
-
Signs
-Moniton Pair LULS
Medicator As
ORDERED
-
ADMINISTER
-
INSERT , TOBE
NG
- INTEMITTINT SUCTION
-
Collect Blood Sample For
Testig
- . PT ON
ED DIAGNOSIS
ON PAN MANAGEMENT
-
ED PT
ON
DIET
ED PT
-
MEDICATION SIDE EFECTS
ON
-
ED PT
vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION HELLO , My NAME Is BEN , I'
YOUR NORSE HERE
TODAY)
IN THE EMERGENCY DEPARTMENT
.
Your name, position (RN), unit you are
working on
PT STAN CHECKETTS 52
Y/0 WHO CAME IN
WCOMPLAINTS
ON SEVERT ABDOMINAL PAIN, N/V
SITUATION
Is ,
,
·
LAST FEW DAYS .
PAIN "4/10"
· ALDOMINAL
Patient’s name, age, specific reason for visit TUBE PLACED
ABOVE 92%
· NG
02
NC 4L OP
·
XRAY CONFERMED OBSTRACTIO
·
ABDOMINAL
PRIMARY DIAGNOSIS SMALL BowOL OBSTRUCTION
BACKGROUND
· :
TODA & 04/16/201200
Admissio
PRN NAUSEA
·
Patient’s primary diagnosis, date of ORDERS IU PUSH EVERy
6HR FOR
P-Bog PRN Moderate PAN Ke
ONDANSTRON
·
For
& 4Rs
admission, current orders for patient ·
IU PUSH EVERY
2 LUL 8-10
· MORPHine My RHR PAAN
IV EVERY
·
MORPHINE Prg
RER At t
To
·
PT A & Ox 3
ASSESSMENT =
·
NP O
110/80
Current pertinent assessment data using head · BP
106 RAPID
HR
to toe approach, pertinent diagnostics, vital
·
RR 22
·
signs TEMP 94 F
Nk e RL/mm
·
93%, /04
Uza
Spoz
·
COLD TO TOUCH
· POOR SKIN TURGUR
RECOMMENDATION · Cont I V
. .
FLUIDS
.
For PAIN LUL
Any orders or recommendations you mayhave · MONITOR
for this patient MEDICATIONS
AS ORDERED
o ADMIN
PATIENT EDUCATION WORKSHEET
NAME OF MEDICATION, CLASSIFICATION, AND INCLUDE PROTOTYPE
MEDICATION: BUPRENORPHINE ·
CLASSIFICATION: ANALGESIC
· THERAPEUTIL
: OPIOID
· PHARMACOLOGIL OPZozD :
AGONISTS/ANTAGONISTS
PROTOTYPE: Schedule
SAFE DOSE OR DOSE RANGE, SAFE ROUTE
1-6 ARS As NEEDED CAN REPEAT INITIAL DOST AFTER 30 Min
EVERY
IV 03
.
~
: .
mg
PURPOSE FOR TAKING THIS MEDICATION
IV: MANAGAS MODERATE TO SEVERE ALOTE PAIN
PATIENT EDUCATION WHILE TAKING THIS MEDICATION
DT ON THE RISK OF ABUSE & MISUSE
DINSTRUCT
SIDE
EFFECTS OF DROWSINESS Or DiZZINESS
2) ED .
PT ON
PT AVOD ALCOHOL WICNS DEPREGSANS
3) ADVISE To
Clinical Worksheet
Date: 03 :
18 2 4
.
Student Name: BENJAMIN WALZAK Assigned vSim: STAN CHECKETTS
Initials: SC Diagnosis: SMALL HCP: JOHN Doe Isolation: N/A IV Type: PERIPHERAL Critical Labs: Other Services:
Location: RIGHT ARM
Age: 52
BOWEL OBSTRUCTION -
CBC
-HB : 20 NA
HCT: 60
Fall Risk: NO
-
WB2 : K
M/F: M Length of Stay: IDAY Consults: GI Fluid/Rate: NS Consults Needed:
-
500 ML - ELECTROlyTT)
NA : 150
Code Status: N/A Transfer: NO over 30min
NUTRITIONIST
-
CL : 188
Allergies: DEMERO
-
Bon 42
-
-
-
CREATININE = 1 ↑
.
Why is your patient in the hospital (Answer in your own words and include the History of present Illness)?:
COMPLAIN OF ABDOMENAL PAN N/V PAST FEW
PT CAME INTO ER ,
OVER
DAYS .
HAVE LEAD TO PTS SMALL ABDOMINAL OBSTRUCTIO
OF SURGERCES COULD
HISTORY
Health History/Comorbities (that relate to this hospitalization):
SURGicaL HISTORY O HENZA REPAIR AND ADDENDELTOMY
CAN LEAD TO SMALL BOWEL OBSTRUCTION
THESE SURGERIES
Shift Goals/ Patient Education Needs: MEDICATION ADMINISTATION
IHR AFTER
1. PT WILL LOWN PAINSCALE
I HR AFTER MEDICATION ADMINISTRATION
REPORT IMPROVEMENT OF NAUSEA
2. PT WIN
AFTER Medication Administad
Of Dehydration
PRESENT W/EMPROUD 5XS
3. PT WILL
UNDERSTAND SXS OF SMALL BOWEL OBSTRUCTION
4. PT WILL
Path to Discharge: AFTER MED Administratio
PAIN IHR ATER INSETIN O NG TUBE
.
PT WILL REPORT ABDomina Discomfort IHR
LOWER
Of
-
IMPROVEMENT ADMINEstate
-
PT WILL Report NAUSEOUS AFTER MED .
LESS AHR
-
PT WILL Report
Feeling
Path to Death or Injury: AFTER MED .
ADMIN
PAIN SAMYCUL OR HIGHER
.
-
PT REPORTS
N/V IHR AFTER MED ADMIN
.
PT REPORTS Of NG TBE
DISCOMFORT/PAN After PLALEMENT
~
- PT REPORTS
-
PT DOES UARBALY
NOT
EXPRESS THE CORRECT SXS OF SMALL BOOTL OBSTRUTTON
Alerts:
What are you on alert for with this patient? (Signs & Symptoms) Management of Care: What needs to be done for this Patient Today?
ORDERED
1. AB Dominat 1. ADMIN MEDINTON AS
PAIN/Discomfort
AS ORDERED
FLUIDS
2. N/V 2. ADMIN IU
Abdominal Assessment
3. WEARNES3/DIZZENESS 3. Preform
VitaL SXS AND PAIN LULFREQUENTLY
4. Assess Moniton
LABS & VALVEs
What Assessments will focus on for this patient?
5. Assess
& Monitor
(How will I identify the above signs &Symptoms?)
ABDonin 6. PTS SPO2 RIMAINS ABOUT 92% W/OxygEN
1. Preform
PAIN Assessment
AND
2. Assess CBC
, Priorities for Managing the Patient’s Care Today
ABGS SERUM
,
1. REDUCE ABPONMAL
PAIN W/MEDS ORDERED
ELEZTROLYTELAB
3. WV/
VALUES
FEELLY
OF NAUSTA MEDS ORDERED
Assess SKIN 2. REDUCE
& Sutton
MUCOUS MEMBRANES RELIEF WING TUB AND INTERMITTENT
3. ACHIEVE ABDONAL
FOOr DEHYDRATIO
List Complications may occur related to dx, procedure, comorbidities:
4. IMPROVE PT HyPRation STATUS W/IV FLUIDS AS ORDERED
1. ELECTROLYTE
[MBNLANCE
-
TOW
2. INFECT
What aspects of the patient care can be Delegated and who can do it?
VETALS
3. METABOLIL - UAP CAN TARE
ALRALOSIS ASSIST W/Personal Hygime
-
UAP CAN
BLOOD SPECImars TO SEVID TO LAB
Colle
CAN
What nursing or medical interventions may prevent the above Alert or complications? -
CPN
CARE
NG TUBE
- LPN CAN PREM
PASS MEDS
1. MONITOR VITAL
CAw
SIGNS -
LPN
2. MEDiato,
ADcher.
FLUIDS
3. ADMIN IU
& O's
Monitor I
4. NG TBE INTERMENT
Suction
