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This Concept Map, created with IHMC CmapTools, has information related to: 9-28-09 no. 2, VS BP124/69, RR 20, O2 97, Temp 97.5 oral, HR 96; BNC @2L; AAO X 3, strong heart sounds, regular, expiratory wheezing on auscultation in all fields, skin warm, pink, cap. refill ɛ, peripheral edema 2+ on all extremities; pulses - rad 3+ bilat, dors. ped. rt 1+, lt 2+, reg. respirations; lt subclavian vascath, 1. INT lt hand, 2. INT lt forearm; abdomen soft, bowel sounds present in all quaduarants, full code. Medications Allergra, Flonase, Novolin R, Flora Q, Prevacid,Reglan, Heparin 5000 units/ml, Cordarone, Cancidas, Cardizem, Benadryl, Drisdol,Flagyl, Renagel, Tygacil, Ambien, 76 yr old WM Assessed pt VS BP124/69, RR 20, O2 97, Temp 97.5 oral, HR 96; BNC @2L; AAO X 3, strong heart sounds, regular, expiratory wheezing on auscultation in all fields, skin warm, pink, cap. refill ɛ, peripheral edema 2+ on all extremities; pulses - rad 3+ bilat, dors. ped. rt 1+, lt 2+, reg. respirations; lt subclavian vascath, 1. INT lt hand, 2. INT lt forearm; abdomen soft, bowel sounds present in all quaduarants, full code., 76 yr old WM Assessed developmental stage Ego Integrity vs. Despair, 76 yr old WM Diet At this time, patient is on a 1500 soft diet because he needs sufficient caloric intake due to beingon hemodialysis.Soft to assist with nutrientbreakdown. Some examples would include soups, mashed potatoes, pastas, oatmeal, applesauce, bananas., 76 yr old WM Nsg Dx #2 Excess fluid volume r/t decreased urinary output secondary to renal failure AEB hemodialysis x 3/wk, peripherical edema., Infection r/t altered immune fucntioning secondary to end-stage renal failure AEB fever spikes, elevated seg. (79), and cultures positive for anisocytosis & macrocytosis Goal #2 Patient will demonstrate appropriate hygienic measures before end of shift., Patient will show signs of improvement from current infection before discharge Evaluation Goal partially met. Patient shows improvement but labs still show signs of infection. Continue with interventions., Patient will demonstrate appropriate hygienic measures before end of shift. Evaluation Goal met. Patient stated and demonstrated understanding of appropriate hygienic measures., Infection r/t altered immune fucntioning secondary to end-stage renal failure AEB fever spikes, elevated seg. (79), and cultures positive for anisocytosis & macrocytosis Goal #1 Patient will show signs of improvement from current infection before discharge, Excess fluid volume r/t decreased urinary output secondary to renal failure AEB hemodialysis x 3/wk, peripherical edema. Based on VS BP124/69, RR 20, O2 97, Temp 97.5 oral, HR 96; BNC @2L; AAO X 3, strong heart sounds, regular, expiratory wheezing on auscultation in all fields, skin warm, pink, cap. refill ɛ, peripheral edema 2+ on all extremities; pulses - rad 3+ bilat, dors. ped. rt 1+, lt 2+, reg. respirations; lt subclavian vascath, 1. INT lt hand, 2. INT lt forearm; abdomen soft, bowel sounds present in all quaduarants, full code., Patient will demonstrate appropriate hygienic measures before end of shift. To accomplish 1. Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. 2. Note and report laboratory values 3. Carefully wash and pat dry skin. 4. Assess shin for color, moisture, texture, and turgor. 5. Use appropriate "hand hygiene" 6. Administer antibiotics as ordered. 7. Teach patient appropriate hygienic care with hand washing;bathing; and hair, nail, and perineal care. 8. Follow standard precautions. 9.Teach patient risk factors contributing to wound infections, smoking, and higher body mass index. 10. RE: Influenza: Teach frequent hand washing, limited contact with sick person, use of masks by caregiver and sick person, and keeping sick person in a "sick room"., 76 yr old WM Nsg Dx #3 Hopelessness r/t prolonged activity restriction and deteriorating physiological condition secondary to end-stage renal failure AEB closing eyes, lack of involvement in care, turning away from speaker, not cooperating with care, easily aggitated., Patient will maintain clear lung sounds, no evidence of dyspnea or orthopnea by end of shift. To accomplish 1. Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. 2. Keep HOB elevated 30 to 45 degrees. 3. Monitor vital signs; note decreasing BP, tachycardia, and tachypnea. 4.Monitor for the devlopment of conditions that increase the risk for excess fluid volume. 5.Provide scheduled rest periods. 6. Assess patient knowledge of disease process causing excess fluid volume. 7. Teach patient about end-stage renal failure and complications of excess fluid volume, including when to contact the physician. 8. Teach and reinforce knowledge of medications. 9. Instruct patient to make primary physician aware of medications ordered by other physicians and before using OTC drugs. 10.Spend time with patient to detect any factors that may interfere with the patient's compliance with the fluid restriction or restrictive diet., 1. Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. 2. Keep HOB elevated 30 to 45 degrees. 3. Monitor vital signs; note decreasing BP, tachycardia, and tachypnea. 4.Monitor for the devlopment of conditions that increase the risk for excess fluid volume. 5.Provide scheduled rest periods. 6. Assess patient knowledge of disease process causing excess fluid volume. 7. Teach patient about end-stage renal failure and complications of excess fluid volume, including when to contact the physician. 8. Teach and reinforce knowledge of medications. 9. Instruct patient to make primary physician aware of medications ordered by other physicians and before using OTC drugs. 10.Spend time with patient to detect any factors that may interfere with the patient's compliance with the fluid restriction or restrictive diet. After completion Goal not met. Patient still presents with wheezing on auscultation in all fields. Continue with interventions., Excess fluid volume r/t decreased urinary output secondary to renal failure AEB hemodialysis x 3/wk, peripherical edema. Goal #1 Patient will maintain clear lung sounds, no evidence of dyspnea or orthopnea by end of shift., Patient will explain measures that can be taken to treat or prevent excess fluid volume, especially fluid and dietary restrictions and medications before discharge. Evaluate Goal partially met. Patient still adjusting to the knowledge of his worsening condition. States understanding but recommend a consult with renal specialist before discharge., 76 yr old WM Diagnosed with Acute Pancreatitis, Kidney Failure, 76 yr old WM Nsg Dx #1 Infection r/t altered immune fucntioning secondary to end-stage renal failure AEB fever spikes, elevated seg. (79), and cultures positive for anisocytosis & macrocytosis, 1. Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. 2. Keep HOB elevated 30 to 45 degrees. 3. Monitor vital signs; note decreasing BP, tachycardia, and tachypnea. 4.Monitor for the devlopment of conditions that increase the risk for excess fluid volume. 5.Provide scheduled rest periods. 6. Assess patient knowledge of disease process causing excess fluid volume. 7. Teach patient about end-stage renal failure and complications of excess fluid volume, including when to contact the physician. 8. Teach and reinforce knowledge of medications. 9. Instruct patient to make primary physician aware of medications ordered by other physicians and before using OTC drugs. 10.Spend time with patient to detect any factors that may interfere with the patient's compliance with the fluid restriction or restrictive diet. After completion Goal partially met. Patient still adjusting to the knowledge of his worsening condition. States understanding but recommend a consult with renal specialist before discharge., 1. Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. 2. Note and report laboratory values 3. Carefully wash and pat dry skin. 4. Assess shin for color, moisture, texture, and turgor. 5. Use appropriate "hand hygiene" 6. Administer antibiotics as ordered. 7. Teach patient appropriate hygienic care with hand washing;bathing; and hair, nail, and perineal care. 8. Follow standard precautions. 9.Teach patient risk factors contributing to wound infections, smoking, and higher body mass index. 10. RE: Influenza: Teach frequent hand washing, limited contact with sick person, use of masks by caregiver and sick person, and keeping sick person in a "sick room". After completion Goal met. Patient stated and demonstrated understanding of appropriate hygienic measures.