Concept Map 9 Graded

Data Collection

Student Name: Jennifer Carey Assignment #: 8 Date(s) of Care: 12/7/11 Gender M F

Age Range Neonate <1 1-4 5-9 10-14 15-19 20-29 30-39 40-49 50-59 60-69 70-79 >80

Allergies:Actos, demetrol, enalapril, Fosamax, IVP dye, Lipitor, lisinopril, nicotine patch, raloxifene Admission Date: 4/18/2011 Code Status: DNR

Primary Medical Diagnosis Diabetes Mellitus II

Comorbidities: Hypercholesterolemia, macular degeneration, vascular dementia, Chronic Obstructive Pulmonary Disease (COPD),

hypertension, trigeminal neuralgia, Gastroesophageal Reflux Disease (GERD)

Developmental Stage: Integrity vs Despair (Erickson)

Pathophysiology of above conditions:Name: Diabetes Mellitus IIPatho: In type 2 diabetes, the pancreas continues to produce some insulin, it is just not enough for the body’s needs or it is used poorly by the body tissues (Corwin, 2008).Etiology: Insulin resistance, decreased pancreatic production of insulin and inappropriate glucose production by the liver all play a role in developing type 2 diabetes (Corwin, 2008).S/S: Usually nonspecific and include fatigue, recurrent infections, prolonged wound healing and vision changes (Corwin, 2008).R/T Meds: Prandin with meals.

Name: HypercholesterolemiaPatho: High levels of cholesterol on the blood. Abnormalities of lipoproteins which are the particles which carry the cholesterol. Cholesterol is an essential component to cell membranes and steroids. 3 types of cholesterol: LDL, VLDL and HDL. Can lead to heart disease.Total= <200. HDL= >60 carries lowest risk. LDL= <70. Triglycerides= <150 (“High Cholesterol,” 2011)Etiology: Environmental (dietary/obesity) and genetic factors (“High Cholesterol”, 2011).S/S: usually asymptomatic hence the importance of having it checked (“High Cholesterol”, 2011).

Name: Macular DegenerationPatho: There are two different kinds of macular degeneration: wet and dry. In dry macular degeneration there are pigment changes in the retina, yellow spots and areas of chorioretinal atrophy. There is no edema, hemorrhage or exudation. Ninety percent of clients have wet macular degeneration which begins as dry. Abnormal vessels form under the retina. There is edema or hemorrhage which may cause retinal detachment. Eventually, neovascularization occurs causing and elevated scar (Garg, 2008).

Revised September 2011 Page 1 of 14

Etiology: Some risk factors for developing macular degeneration are genetic, smoking, heart disease, hypertension, age and a diet low in omega 3 fatty acids (Garg, 2008).S/S: Dry: loss of central vision, pigment changed. Usually bilateral. Wet: Rapid vision loss. Central blind spot. Usually unilateral. Retinal edema (Garg, 2008).R/T Meds: None

Name: Vascular DementiaPatho: It is a subtle, progressive decline in memory and cognitive function. This occurs when blood supply to the brain is reduced (Block, Smith, & Segal, 2010).Etiology: A history of a stroke, small vessel disease or a mixture of the two can cause vascular dementia. Most commonly, there is a blockage of small blood vessels somewhere in the vascular system of the brain. Hypertension is thought to be a cause of vascular dementia (Block et al., 2010).S/S: Slowed thinking, forgetfulness, mood changes (depression), confusion, dizziness, balance problems, bowel and bladder incontinence, slurred speech, aphasia, reduced ability to function in daily life (Block et al., 2010).R/T Meds: Celexa

Name: Chronic Obstructive Pulmonary DiseaseCOPD is a disease in which an airflow obstruction caused by chronic bronchitis of emphysema is present. Usually a progressive, non-reversible (completely) condition. There is inflammation also. Chronic bronchitis is defined as a chronic productive cough for at least 3 months in 2 or more years. Emphysema is an abnormal permanent enlargement of the airspaces with structural changes (Lewis, Heitkemper, & Dirksen, 2000).Patho: Emphysema: 2 types: centrilobular and panlobular. In centrilobular, the primary area of involvement is the central part of the lobule. Respiratory bronchioles enlarge, the walls are destroyed, and the bronchioles become confluent. Chronic bronchitis is often associated with centrilobular emphysema which is more common. Panlobular involves distention and destruction of the whole lobule. Bronchioles, alveolar ducts and sacs, and alveoli are all affected. There is a progressive loss of lung tissue and a decreased alveolar-capillary surface area. Chronic bronchitis: an excessive production of mucus in the bronchi accompanied by a recurrent cough. Structural changes include hyperplasia of mucous-secreting glands in the trachea and bronchi, increase in goblet cells, disappearance of cilia, chronic inflammatory changes and narrowing of the small airways and altered functioning of alveolar macrophages leading to more infections (Lewis, Heitkemper, & Dirksen, 2000).Etiology: Cigarette smoking is the primary cause of COPD and is true for this client. Other etiologies include recurrent respiratory tract infections, high levels of air pollution, heredity and aging (Lewis, Heitkemper, & Dirksen, 2000).S/s: Emphysema: Dyspnea on exertion that becomes progressively worse, Coughing with no sputum to little sputum, flattened diaphragm leading to barrel chest, chest breathing, hypoxemia, hypercapnia late in disease, thin and underweight, finger clubbing (Lewis, Heitkemper, & Dirksen, 2000).R/T Meds:

Name: Hypertension is a sustained elevation in BP. When systolic pressure is greater than 140 or diastolic pressure is greater than 90. Diagnosis of hypertension comes when elevated readings occur on 3 consecutive occasions during several weeks. High BP means the heart is working hard, putting the heart and the vessels under stress (Lewis, Heitkemper, & Dirksen, 2000).Revised September 2011 Page 2 of 14

Patho: An increase in cardiac output or systemic vascular resistance (SVR) must occur for pressure to rise. The true diagnosis of hypertension comes when there is a persistence elevation is SVR (Lewis, Heitkemper, & Dirksen, 2000).Etiology: Heredity, Water and sodium retention, altered renin-angiotensin mechanism, stress, insulin resistance, smoking, race, sex and age are some causes of hypertension (Lewis, Heitkemper, & Dirksen, 2000).S/s: None at first. Usually a patient seeks medical attention because of secondary issues hypertention causes or the high BP effects on organs like CAD (Lewis, Heitkemper, & Dirksen, 2000).R/T Meds:

Name: Trigeminal NeuralgiaPatho: Trigeminal neuralgia is a nerve disorder. The trigeminal nerve is the fifth cranial nerve and has both sensory and motor branches. The mandibular and maxillary branches which are sensory are involved in trigeminal neuralgia (Corwin, 2008).Etiology: No specific cause has been identified. Some thoughts include: nerve compression by tortuous arteries, demyelinating plaques, herpes virus infection, infection of the teeth or jaw, and brainstem infarct. Attacks are usually brief lasting just 2 to 3 minutes and usually happen on one side of the face. Recurrences are unpredictable. Things that may bring an attack on are: chewing, teeth brushing, hot or cold air on the face, yawning, washing the face, or even talking. Touch and tickle seem to be great triggers (Corwin, 2008).S/S: Abrupt onset of pain in lips, upper or lower gums, cheek, forehead or side of the nose is a classic feature of trigeminal neuralgia. Other signs include: intense pain, twitching, grimacing, and frequent blinking and tearing of the eye (Corwin, 2008).R/T Meds: Tegretol. This drug therapy may work because it stabilizes the neuronal membrane (Corwin, 2008).

Name: GERD Gastroesophageal refluxPatho: Poor esophageal motility decreases the clearance of the gastric juice. Delayed gastric emptying can increase volume and pressure (Patti, 2011).Etiology: Stomach contents backing back up into the esophagus (Patti, 2011).S/S: Typical symptoms include: heartburn, regurgitation, dysphagia (sensation of food being stuck) can be an advanced symptom (Patti, 2011).R/T Meds: Prilosec

Course-specific data attached


Laboratory TestsDate Time Abnormal/Significant Lab Findings Normal range per Facility/Lab How does the result relate to the

pathophysiology of your patient’s condition(s)?

11/29/11

8/4/11

7/19/11

0001

0001

0615

Hgb A1C 6.6%Est. Ave. Glucose 146 mg/dL

Carbamazapine 6.5 mcg/mL

TSH 1.45 uiU/mL

4-5.6%

Suggested level: 8-12 mcg/mL

0.4-4.5 uiU/mL

In a patient with diabetes, it is considered controlled if they are under 7%, making the

client’s 6.6% normal. Hgb A1C is a measure of diabetes control over weeks or months (Malarkey

& McMorrow, 2005).

According to the safe range of Tegretol, the client is safe (Malarkey & McMorrow, 2005). If her current dose of 200 MG BID is controlling her

symptoms, I would not anticipate a change in her dose to make her in the therapeutic range.

Stimulates thyroid gland to produce thyroid hormones (Malarkey & McMorrow, 2005). Client’s

current medication dose is working.

DiagnosticTestsDate Time Impressions How does the result relate to the

pathophysiology of your patient’s condition(s)?

4/16/11 1425 Chest Xray Pa and Lat: 1.) LLL opacity- atelectasis and or pneumonia. 2.) No failure.

Atelectasis is a partial lung collapse caused by blocked air passages or by pressure on the outside of the lung. Risks include mucus, pleural effusion, prolonged bedrest without position change, and shallow breathing. Signs and symptoms include cough, chest pain, and breathing difficulty. Treatment includes breathing exercises, turning and ambulating (“Atelectasis", 2010). Pneumonia is an infection of the lung that is bacterial, viral or fungal. Causes include bacteria or viruses living in the nose, sinus or mouth that can spread to the


4/22/11 2201 Ct Head wo Contrast: Moderate diffuse cerebral atrophy and moderate microangiopathy, chronic. No acute abnormality.

lungs, clients can breathe the bacteria directly into their lungs, or with aspiration pneumonia, fluids or food is inhaled into the lungs unintentionally. Risk factors for pneumonia are COPD, smoking, diabetes, recent cold, and impaired consciousness. Signs and symptoms include cough (can be productive), fever, chills and shortness of breath. Treatment usually consists of IV fluids and antibiotics, supplemental oxygen and breathing treatments (“Pneumonia”, 2011).

Microangiopathy generally refers to age related changes in white matter usually due to hypertension that can cause a decline in cognitive function (Corwin, 2008).

Enter the labs/diagnostics under related Key Problems


MedicationsGeneric & Brand

NamesPrescribed Dose &

Recommended Range

Why is my patient getting this

medication?

Potential Side Effects and/or Adverse

Reactions

Drug to DrugFood to Drug

Interactions/Cautions

What will I monitor about this medication

r/t my patient’s problems?

PrandinRepaglinide

Antidiabetic/ Meglitinides

2 mg PO with meals

Rec: 0.5-4 mg taken before meals not to exceed 16 mg/day.

Type 2 diabetes

Action: Stimulates the release of insulin from pancreatic beta

cells by closing K+ channels which

opens Ca+ channels. This is followed by a

release of insulin.

AnginaChest pain

Hypoglycemiahyperglycemia

With Lopressor: may result in hypoglycemia, hyperglycemia, or

hypertension.

With synthroid: may result in decreased effectiveness of the antidiabetic agent.

With tegretol: may result in decreased repaglinide

plasma concentrations.

Blood sugars. S/s of hypoglycemia: sweating, hunger, abdominal pain,

hunger, weakness, tachycardia, tremor.

Ensure client is taking in food after taking the

med.

LopressorMetoprolol

Beta Blocker

50 mg PO QAM

Rec: 25-100 mg/day up to 450 mg/day

Hypertension

Action: Blocks beta 1 receptors. Decreases

BP and HR and the workload of the

heart.

InsomniaNauseaFatigue

BradycardiaWeakness

Increased cholesterol and blood sugar.

CHF/PULMONARY EDEMA

With celexa: may result in increased metoprolol

plasma concentrations and possible loss of metoprolol

cardioselectivity.

With Prandin: may result in hypoglycemia,

hyperglycemia, or hypertension.

Taking Lopressor with food may increase the

concentration.

BP and HR before administration.

Intake and Output ratios and weights.

S/S CHF (dyspnea, rales, crackles, weight gain,

edema, JVD).

CozaarLosartan

Angiotensin 2 Receptor Antagonist

(like an ARB)

100 mg PO QAM

Rec: 25-100 mg/day

Hypertension

Action: Blocks the binding of

angiotension 2 to specific tissue

receptors found in vascular smooth

DizzinessAnxiety

ConfusionCough

Upper Resp. InfectionInsomnia

HypotensionVisual changes

None. BP and HR before administration.

S/S of angioedema (dyspnea, facial swelling)

Electrolyte balance


muscle and adrenal glands. Blocks the

vasoconstriction and release of

aldosterone. Decrease in BP by a

decrease in peripheral resistance

and blood volume.

ANGIOEDEMA

SynthroidLevothyroxine

Hormone Supplement

25 mcg PO QAM (0600)

Rec: 50-200 MCG Daily (dose titrated based on TSH, T3,

T4)

Hypothyroidism

Action: Synthetic hormone

replacement. Increases cellular

metabolism, plays a role in growth, CNS and bone function,

body temp,increases oxygen

consumption, respiration, HR,

metabolism of fats, carbs and proteins.

palpitationsappetite increased

tachycardianervousness

tremorweight lossdiaphoresis

diarrheaabdominal cramps

insomniafever

headachealopecia

heat intolerancenauseaanxiety

Always give on an empty stomach preferably before

breakfast.

With tegretol: may result in decreased levothyroxine

effectiveness.

With Prandin: may result in decreased effectiveness of

the antidiabetic agent.

Labs if available (TSH/T3/T4).

S/S hyperthyroidism (irritability, insomnia, hyperthermia, wt loss,

palpitations, tachycardia, increased BP, sweating).

PrilosecOmeprazoleProton Pump

Inhibitor

40 mg PO QAM (0600)

Rec: up to 120 mg/day

GERD

Action: Suppresses gastric acid secretion

Abdominal painDiarrhea

FlatulenceN/VHA

Steven Johnson’s Syndrome

With Celexa: May increase exposure to Celexa

resulting in risk of QT interval prolongation.

With tegretol: may result in an increased risk of

carbamazepine toxicity.

Assess for epigastric pain or abdominal pain.

Blood on stools, emesis or gastric content.


TegretolCarbamazepineanticonvulsants

200 mg PO BID (AM and PM)

Rec: 600–1200 mg/day in divided doses Q 6–8 hrs

Trigeminal Neuralgia

Action: Decreases synaptic transmission

in the CNS by affecting Na channels

in neurons.

Suicidal thoughts (also a mood stabilizer),Steven Johnson’s

syndrometoxic epidermin

necrolysis, agranulocytosis,aplastic anemia,

thrombocytopenia.

With Tylenol: May increase risk of Tylenol hepatotoxicity

With synthroid: may result in decreased levothyroxine

effectiveness.

With Prilosec: may result in an increased risk of

carbamazepine toxicity.

With Prandin: Concurrent may result in decreased

repaglinide plasma concentrations.

FOOD: No grapefruit juice.

Assess for facial pain (location, intensity and

duration).Monitor WBC r/t

agranulocytosis side effect.

TylenolAcetaminophen

Nonopiod analgesic

650 mg PO Q4 hrs PRN pain

Rec: 325–650 mg PO Q 4–6 hrs not to

exceed 4 grams (or 2.5 g in

renal/hepatic patients) in 24 hrs

Pain r/t trigeminal neuralgia

Action: thought to inhibit prostaglandin synthesis and elevate

pain threshold.

Hepatic FailureHepatotoxicityRenal failure

RashHA

NauseaLow WBC counts

With tegretol: May increase risk of Tylenol hepatotoxicity

Ensure client is not receiving more than the

max dose per day (4 grams).

Pain assessment to include location,

duration, intensity, pain scale number

CelexaCitalopram

SSRI

20 mg PO Daily (AM)

Rec: up to 40 mg/day in gero

patients

Action: Inhibits the reuptake of

serotonin causing a build up

Neuroleptic malignant syndrome

Suicidal thoughtsApathy

ConfusionDrowsinessInsomniaWeakness

Abdominal painDiarrhea

Dry mouthDyspepsiaFlatulence

With Prilosec: May increase exposure to Celexa

resulting in risk of QT interval prolongation.

With Lopressor: may result in increased metoprolol

plasma concentrations and possible loss of metoprolol

cardioselectivity.

Clients mood and any changes.

Assess for serotonin syndrome: mental

changes like agitation, hallucinations and coma,

autonomic instability: tachycardia, labile BP,

hyperthermia, neuromuscular

aberrations: hyperreflexia,

incoordination and Gi


SweatingTremor

Serotonin syndrome

symptoms: n/v and diarrhea.

Miralaxpolyethylene glycol

Osmotic laxative

17 gm PO (in 8 oz water) PRN constipation

Rec: 17 g in 8 oz water, may be used for up to 2 weeks.

Constipation

Action: Draws water into the stool-

increases the salt concentration in the large intestine, which

causes water to be drawn into the intestine; the

increased amount of water in the intestine

softens the stools.

Abdominal bloatingCrampingFlatulence

Nausea

None however I would not give it with other

medications

Assess for abdominal distention, bowel sounds

usual bowel function, color, consistency and

amount of stool produced.

KenalogTriamcinolone 0.1%

Corticosteroid

1 Application Topically BID to leg rash until resolved

Rec: apply 3-4 times a day

Rash

Action: Suppresses immune response and inflammation

BurningDryness

FolliculitisHypersensitivity

None. Skin assessment with attention to degree of

inflammation and pruritus. Watch for s/s infection like increased

pain, erythema, purulent exudate.

Oxygen 2 LPM via NC(titrate to 90%)

Recommended Range: 1-6 L per NC

Hypoxia r/t COPD

Action: improved perfusion. Saturated blood with oxygen.

Dry mucus membranes. Bloody Nose.

None. O2 saturation.Lung sounds.


RFS BID

Rec Range:

Diabetes type 2 Hyper: Increased thirst, ha, blurred vision, frequent urination,

fatigue, BS >180 mg/dL

Hypo: tremor, sweating, hunger, anxiety. Confusion, heart

palpitations.

None Monitor what the result is. Ensure client is taking Prandin. Ensure client is

not eating differently than normal. Ensure

client is not consuming an excessive amount of

carbs.



Demographic DataAssignment # 9 Age range: >80 Gender: Female Ht: 137.2 cm Wt: 85 kg BMI: 32.1 (Obese) Code Status: DNRMedical Diagnosis: Diabetes Mellitus II Diet/Texture: Calorie Restricted, small portions Allergies: Actos, demetrol, enalapril, Fosamax, IVP dye, Lipitor, lisinopril, nicotine patch, raloxifeneVS: 11/11/11: T: 97 P: 76 RR: 18 BP: 120/72

Gordon's Functional Health Pattern

SubjectiveClient states she has a "diabetes problem"Client is open to small portion meals.

ObjectiveBMI 32.1Client has gained 20# since admission in April.


Subjective

ObjectiveClient uses oxygen at 2 LPM ncClient has a history of pneumonia or atelectasis.


SubjectiveClient states, "I can't do it by myself" when asked about dressing herself.

ObjectiveStaff assists client in dressing and sets her up at the sink for oral care and hair combing inthe am.

Priority #1 Nursing Diagnosis: Imbalanced Nutrition: More than Body Requirements

RT increased intake and decreased activity

AEB BMI of 32.1

Priority #1 Nursing Diagnosis: Impaired gas exchange

RT ventilation-perfusion inequality (Ackley & Ladwig, 2010)

AEB need for supplemental oxygen

Priority #1 Nursing Diagnosis: Self Care Deficit

RT fatigue

AEB client’s need for help to dress

SMART Patient Goal:

Client will have no weight gain during the two weeks SN will be following her.

SMART Patient Goal:

Client will maintain clear lung sounds during the shift 12/7/2011.

SMART Patient Goal:

Client will participate in ADL’s today by breakfast time.

SMART Interventions followed by Evidenced-Based Rationale (minimum 3):

1. Client will walk to and from breakfast with gait belt, walker, oxygen, and staff member during today’s shift.Rationale: Walking burns more calories than being pushed to the dining room in her wheel chair.

2. Client will have small portions for all meals today.Rationale: A decrease in calorie intake should helo the client not gain weight.

3. Client will be weighed and have it charted and assessed at least once per week on Wednesdays.Rationale: SN must have a weight at least once a week to be able to assess if the client is successful in not gaining weight.

4. Client will be compliant with taking her Prandin at meal timesRationale: Taking her medication will help control her diabetes.


1. SN will auscultate breath sounds Q4 hours.Rationale: Checking for the presence of crackles or wheezes will alert the nurse to a problem which may lead to an exacerbation of hypoxia (Ackley & Ladwig, 2010).

2. SN will monitor oxygen saturation Q4 hours.Rationale: This would be another indicator of a problem that could lead to adventitious lung sounds.

3. Client will reposition every 2 hours and PRN.Rationale: Keeping clients active will decrease atelectasis and risk for pneumonia which can cause adventitious lung sounds (Ackley & Ladwig, 2010).

4. SN will ensure oxygen administration is being delivered by appropriate device (Ie nasal cannula) at an appropriate liter flow by lunch time.Rationale: There is a fine line between proper oxygenation and over oxygenation (Ackley & Ladwig, 2010)


1. SN/Staff will assist client with AM dressing and grooming by breakfast time.Rationale: Client will need help getting dressed for breakfast.

2. SN/Staff will keep the client’s personal preferences in mind when dressing and grooming before breakfast.Rationale; Keeping the client’s preferences in mind helps promote self esteem (Ackley & Ladwig, 2010).

3. Client will assist in dressing and grooming herself rather than letting SN/Staff do it for her by breakfast time.Rationale: Doing these tasks on her own will help promote independence.

Evaluation (at end of day, did client reach stated goal?) Evaluation (at end of day, did client reach stated goal?) Evaluation (at end of day, did client reach stated goal?)

SMART: Specific Measureable Appropriate Realistic Time element References on back or on attached page.


Post Conference ReportWhat new Nursing knowledge did you learn today?

Was it effective or able to be utilized in the care of your patient – or a patient?

Any changes in medications, labs or diagnostics you need to be aware of that will change how you will for your patient again?(you will need to complete a new medication sheet, lab or diagnostic sheet if there are changes)

Did you participate in any discharge planning? If not – why not?

Would you change any nursing action done for your patient or with a patient today? What?

What did you observe about the nurses working on the unit you were assigned?


REFERENCES

Atelectasis - PubMed Health. (2010, September 15). National Center for Biotechnology Information. Retrieved December 5, 2011, from Block, J., Smith, M.,

& Segal, J. http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001130/

Vascular Dementia: Signs, Symptoms, Prevention, and Treatment. (June 2010). Helpguide.org: Expert, ad-free articles help empower you with knowledge,

support & hope.. Retrieved December 3, 2011, from http://www.helpguide.org/elder/vascular_dementia.htm

Corwin, E. J. (2008). Handbook of pathophysiology (3rd ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.

DrugGuide.com | Davis's Drug Guide Online + Mobile. (n.d.). DrugGuide.com | Davis's Drug Guide Online + Mobile. Retrieved October 26, 2011, from

http://drugguide.com/ddo/ub/home

High cholesterol - MayoClinic.com. (2011, June 1). Mayo Clinic. Retrieved December 5, 2011, from http://www.mayoclinic.com/health/high-blood-

cholesterol/DS00178

Garg, S. (2008, December 15). Age-Related Macular Degeneration (AMD or ARMD): Retinal Disorders: Merck Manual Professional . THE MERCK MANUALS

- Trusted Medical and Scientific Information. Retrieved December 5, 2011, from

Karch, A. (2008). Focus on nursing pharmacology . (4th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Malarkey, L. M., & McMorrow, M. E. (2005). Saunders nursing guide to laboratory and diagnostic tests. St. Louis: Elsevier Saunders.

Patti, M. (2011, August 19). Gastroesophageal Reflux Disease . Medscape. Retrieved November 14, 2011, from emedicine.medscape.com/article/176595-

clinical#aw2aab6b3b2

Pneumonia - PubMed Health. (2011, May 1). National Center for Biotechnology Information. Retrieved December 5, 2011, from

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001200/


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Concept Map 9 Graded