Zachary

Kelley Concept Map 4/21/15

Concept Map/Care Plan

Patient Scenario: 63 year-old-male admitted with abdominal discomfort and blurred
vision. Wife was at beside. Patient resting in bed when entered room on the Surgical unit.

Pathophysiology of Current Disease:
Diverticulitis: Inflammation of one or more diverticula. Results when undigested
food is retained and compromises the blood supply to the area. Can perforate and
cause intra-abdominal perforation, with peritonitis.

Nursing Diagnosis: Acute pain related to inflamed bowel.

Past Medical History:
Client presents with past medical history including;
Hypertension, hemorrhoids, kidney stones, urinary tract infection, cystitis,
diabetes mellitus type 2, depression and anxiety, appendectomy, and an
unknown status of the chicken pox.

Social History:
Wife was at bedside during hospital stay. Did not talk much of children or other
family members. Wife seems to be primary support and caregiver, although patient
is able to take care of himself.

Assessment Data:
Subjective Data: Patient complaining of some abdominal pain. During time taking
care of, patient reported no pain, no nausea, and no vomiting. Just wanted to sleep.
Objective Data: Client alert and oriented x4, pupils PERRL, no facial droop, Heart
rate regular rate and rhythm, pulses equal bilaterally, capillary refill <3 seconds,
lung sounds clear bilaterally, vital signs posted below, skin warm, dry, intact, pain
indicated in lower abdomen, rated between 0 and 1, dilaudid given before beginning
patient care, denies need for further pain medication, bowel sounds active in all 4
quadrants, no recorded stool during care of patient. Wanted to rest, lights kept low,
as well as volume on TV.



Vital Signs:
Time Temp HR RR BP P02 Pain
0700 98.0 40 22 164/74 97 RA 1
1100 97.2 56 20 148/76 95 RA 2
1500 97.5 68 16 162/92 95 RA 0
1900 97.7 60 16 161/87 97 RA 0


Diagnostic Tests Completed with Results:
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Labs:

Lab Admit (4/10/15) Current (4/1415)
WBC 10.0 9.6
RBC 5.21 4.39 L
Hgb 15.5 12.9 L
Hct 45.3 38.7 L
MCV 86.9 88.2
MCH 29.8 29.3
MCHC 34.2 33.3
RDW 12.6 12.7
Plt 332 262
MPV 9.6 10.2
Immature Gran% 0.2 0.2
Neutrophils 78.3 H 82.1 H
Lymphocytes 14.3 L 9.3 L
Monocytes 6.9 8.3
Eosniphils 0.1 0.0
Basophils 0.2 0.1
Immature Gran # 0.0 0.0
Neutrophils 7.8 H 7.9 H
Lymphocytes 1.4 0.9 L
Monocytes 0.7 0.8
Eosphils 0.0 0.0
Basophils 0.0 0.0
Total Counted 100
Neutrophils 71.0 H
Band Neutrophils 11.0 H
Lymphocytes 9.0 L
Monocytes 9.0 H
Sodium 132 L 138
Potassium 4.6 3.7
Chloride 90.9 L 102.7
CO2 24 18 L
BUN 17 15
Creatinine 1.6 H 1.4 H
GFR 47 L 54 L
Glucose 203 H 60
Calcium 9.3 8.0 L
Total Bilirubin 1.9 H 0.9
AST 14 11
ALT 22 10
Alkaline Phosphate 85 59
CRP 170.6 H
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Total Protein 8.2 6.5
Albumin 3.9 2.9 L
Globulin 4.3 H 3.6 H
A/G Ratio 0.9 L 0.8 L
Amylase 36
Lipase 40
Urinalysis: Clean void, yellow, slightly cloudy, pH (6.0), Specific Gravity (1.005), Protein
(2+ - High), no glucose or ketones, urobilinogen (0.2), RBC (rare), squamous epithelial cells
(rare)
Negative for clostridium difficile, no growth on peripheral blood draw culture
Imaging:
4/10/15 CT Abdomen and Pelvis without contrast: 5.5 cm abcess adjacent to
sigmoid colon, several diverticula, moderately atrophic L kidney with 3 mm
stone, degree of function questioned, 2 mm nonobstructing stone in L kidney,
2mm nonobstructing stone in R kidney, sludge in gallbladder, possible
history of pancreatitis
4/12/15 Abdomen/KUB: Essentially negative exam withouth significant
change from previous on 10/2/13
4/13/15 CT of Abdomen and Pelvis: stable pelvic abcess, atrophy of L kidney
with 2-3 mm proximal left ureteral calculus, punctate nonobstructive
nephrolithiasis bilaterally, diverticulosis of descending and sigmoid colon
4/14/15 Sent for further abdominal imaging, results not received in time

Medications:

Medication Class Reason
Unasyn Inj 3 Gm in normal Broad-spectrum Intraabdominal infections
saline minibag plus 100 mL antiinfective
Q6H
Mylicon PO 80 mg Tab Antiflatulent Flatulence, unlabeled for
QIDPCHS dyspepsia
Flagyl 500mg/NS 100 mL Antiinfective Intestinal amebiasis, amebic
100 mL/hr IV Q8H abcess
Normal Saline 1000 mL 100 Used to supply fluid to the body,
mL/hr IV Q10H prevent dehydration
Tenormin 50 mg Tab Q6H Antihypertensive Mild to moderate hypertension
Amaryl 2 mg Tab Daily Antidiabetic Type 2 diabetes mellitus
Paxil 20 mg Tab Daily Antidepressant General anxiety disorder
Zestril 20 mg PO Daily Antihypertensive (ACE Mild to moderate hypertension
inhibitor)
Lovenox Inj SQ 40 mg Daily Anticoagulant Prevention of DVT, abdominal
surgery at risk for thrombosis
Protonix Inj 40 mg IVP AC Proton pump inhibitor Gastroesophageal reflux disease,
Lunch maintenance
Dilaudid Inj 1 mg IVP Q2- Opioid analgesic Treatment of moderate to severe
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4H/PRN pain
Zofran Inj 4 mg IVP Antiemetic Prevent nausea and vomiting
Q6H/PRN
Tylenol 650 mg PO Q4H/PRN NSAID Pain or Fever


Actual/Potential Complications and Reasons they occur:

1. Bowel Perforation – may form due to irritation of the colon and bowels
a. Interventions/Rationales/Evaluation
i. Considered a medical emergency and surgery is needed
1. Apply SCD’s to prevent deep vein thrombosis
2. No formation of DVT, signs and symptoms
3. Client is free from signs and symptoms of DVT
ii. Incentive Spirometry for prevention of hospital acquired
pneumonia
1. Use of IS 10x per hour while awake
2. Prevent fluid retention in the lungs and development of
pneumonia
3. Lungs are free from fluid and signs of infection
2. Peritonitis – inflammation of the abdominal cavity or lining, often caused by
bacteria from inside the GI tract
a. Interventions/Rationales/Evaluation
i. Monitor urine output
1. Oliguria may develop due to decreased renal perfusion, and
circulating of the toxins
2. Urinary output returns to adequate levels
3. Urinary output of 30 mL or more per hour
ii. Observe skin and mucous membranes for dryness
1. May result in hypovolemia and nutrition deficits due to
vomiting
2. Maintain fluid volume and hydration status
3. Urination and skin turgor return to normal limits
iii. Change position frequently and provide skin care as needed
1. Prevent skin breakdown due to edema and possible
incontinence of urine and bowel
2. No skin breakdown
3. Client is free from skin breakdown and risk is reduced
3. Obstruction – result from inadequate hydration status, low-fiber consumption,
inactivity, and immobility
a. Interventions/Rationales/Evaluation
i. Encourage daily fluid intake of 2000 to 3000 mL
1. Increased fluids to help soften stool formation
2. Client has formed, soft stool
3. Client passes soft, formed stool
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ii. Encourage physical activity and exercise
1. Movement causes the gases to move through the body,
helping to pass formed stool through the colon
2. Help pass obstruction and prevent reformation
3. Client is able to pas stool freely
iii. Encourage increased fiber diet
1. Help soften formed stool, allowing for easier passage
2. Formed, soft, stool, decrease in pain
3. Client passes soft, formed stool, with no reports of pain

Desired Outcomes:

1. Client’s urination and skin turgor return to normal limits
a. Urination is greater than or equal to 30 mL/hr and skin turgor is elastic
b. Body is free from retaining excess fluid
2. Client passes soft, formed stool
a. Client is able to have bowel movement without issue
b. Obstruction is not present due to presence of stool
3. Client is free from signs of DVT
a. Client’s legs are not red and hot to the touch, nor tender
b. Holman’s sign is negative