University Department of Prelicensure Nursing
| Key Problem/ND #4Ineffective Tissue Perfusion related to anemia as evidenced by low HGB and HCT levels |
| Meds Amlodipine (Norvasc) 5mg Daily Colace 50mg Daily Aspirin 81 mg Daily B-Vitamin Complex 0.50 mL IM Daily MiraLAX 17g packet Daily Ticagrelor 60 mg Daily Chronulac 15mL Daily Insulin Humalog AC PRN |
| Key Assessments Vitals: Oral temp: 98.9, RR: 17, BP: 115/66 mmHg, SPO2: 98% on room air Pain: Patient reports 0/10 pain Head to Toe Neurological: Patient is AAOx3. Pupils are equal round and react to light. Patient speech is clear. Patient is nonambulatory. Respiratory: Patient uses accessory muscles to breathe. Patient claims to not be experiencing any shortness of breath. Upon auscultation lungs sound clear in the posterior and anterior lung field. Cardiac: S1, S2 and S3 were present. Capillary refill of more than 2 seconds noted on fingers. Radial pulse was 83 while laying down. Unable to asses’ lower extremities due to bilateral ace bandages that can not be removed due to podiatry orders covering calves and feet. Patient reported an inability to feel his feet. GI: Soft, slightly distended abdomen. Patient does not report any pain upon inspection or palpation Bowel sounds heard in all four quadrants. Patient reported last bowel movement the night before 9/18. GU: Patient reported voiding around 8pm the night before 9/18. Reported no pain or blood in urine. |
| Key Problem/ND 2Risk of Delayed Recovery related to acute renal failure, recent surgical procedures as evidenced by impaired mobility and recent surgeries |
| Patient: J.S 72 y.o male admitted on 9/17. Patient is Allergic to Statins and Benadryl Medical Diagnosis/Surgical Procedure: Acute Renal Failure Fifth ray resection and Calcanectomy with collagen graft and antibiotic beads 9/18 Pt HX: Acute renal failure, Upper GI bleed, Chronic hypertension, Peripheral vascular disease, Diabetes, CKD III, Hyperlipidemia, Heart Failure, anemia, dialysis 3x a week, and Amputation of left foot. 9/17 X-Ray, MRI on right foot |
| Key Problem/ND #1Risk for Infection related to recent surgery and invasive procedure (dialysis) as evidenced by recent surgical history and elevated WBC |
| Key Problem/ND #3Risk for fluid and electrolyte Imbalances related to renal impairment and dialysis evidenced by abnormal sodium and calcium levels and elevated BUN and creatinine |
| LabsWBC: 13.36RBC: 2.21HGB: 7.2HCT: 20.2Glucose: 203 Sodium: 135 Potassium 3.5 GFR: 10Troponin: 40 Calcium: 7.7 BUN: 40Creatine: 5.88 A1C: 6.9Iron: 41 |
CONCEPT MAP FORM
| Problem # and Nursing Diagnosis: Risk for Infection General Goal: The patient will remain free of signs and symptoms of infection while hospitalized | |
| Expected Outcome: The Patient will show no signs of infections during hospitalization including (fever and increased WBC) | |
| Nursing Interventions: Perform Hand Hygiene before and after patient contact Implement strict aseptic technique during wound care and during dialysis Monitor vital signs every 4 hours for signs of infection Educate the parent and family about infection prevent techniques Assess the dressing every 4 hours and surgical site during dressing changes for sign for redness, swelling and drainage | Rationale: Hand hygiene is the most effective measure to prevent the transmission of infectious agents in healthcare settings. It reduces the risk of hospital-acquired infections significantly by eliminating pathogens from the hands of healthcare providers. (Seidelman et al., 2023) Aseptic techniques are crucial in preventing the introduction of pathogens. Using these techniques can help avoid infections in patients to minimize risk of contamination and promote healing. (Nguyen et al., 2019) Vital signs including temperature, heart rate and blood pressure can provide early indicators of infection. This allows for timely intervention. (Seidelman et al., 2023)Patient and family education is important for infection prevention. Understanding proper hygiene practices, wound care and what to report can help prevent infections. (Erdek et al., 2017)Close monitoring of the surgical site can help with early identification of an infection. Redness, swelling and purulent drainage can be indicators of a possible infection. (Seidelman et al., 2023) |
| Evaluation: Compliance with hand hygiene is 100%. Infection remains absent dressing changes are performed aseptically. Vital signs remain within normal limits no fever is recorded. Surgical site remains clean with no signs of infection. Patient can verbalize infection prevent measures correctly. | |
CONCEPT MAP FORM
| Problem # and Nursing Diagnosis: Risk for delayed recovery General Goal: Reduce complications during recovery | |
| Expected Outcome: The patient will achieve a mobility level sufficient to participate in self care activities by discharge | |
| Nursing Interventions: Monitor vital signs and laboratory values daily Encourage gradual mobility with physical therapy support several times a week base on physical therapy and toleration level Monitor dietary intake with every meal and provide nutritional support as needed Encourage participation in self-care activities as tolerated Inspect wound routinely during dressing changes note and drainage, wound measurements deepening or healing. | Rationale: Regular monitoring of vital signs and laboratory values helps identify complications that may impede recovery. Significant changes can indicate problems that require prompt intervention. (Doenges, Moorhouse, & Murr, 2022)Gradual mobilization is critical for recovery as it prevents complications associated with prolonged immobility, such as muscle atrophy and deep vein thrombosis. (Spampinato et al., 2020)Nutrition plays a crucial role in the healing process. Ensuring that the patient receives adequate nutrients supports immune function and tissue repair, which are vital for recovery. (Doenges, Moorhouse, & Murr, 2022)Promoting independence in self-care activities enhances self-efficacy and encourages the patient to take an active role in their recovery. (Saghdaoui et al., 2020) Checking the wound can help identify any problems with healing. (Seidelman et al., 2023) |
| Evaluation: Vital signs remain stable with no lab abnormalities noted, patient ambulated with assistance by discharge, dietary assessment shows improved nutritional intake and wound is not continuing to heal. | |
CONCEPT MAP FORM
| Problem # and Nursing Diagnosis: Risk for fluid and electrolyte imbalance General Goal: The patient will maintain stable fluid and electrolyte levels. | |
| Expected Outcome: The patient will demonstrate laboratory values within normal limits for sodium potassium and calcium for the patient. | |
| Nursing Interventions: Monitor intake and output every shift Check lab values for electrolytes and renal function regularly (daily)Assess for signs and symptoms of electrolyte imbalances such as muscle cramping, nausea, vomiting and weakness check daily Encourage oral fluid intake considering dietary restrictions Monitor for signs of dehydration (e.g., dry mucous membranes, decreased urine output). Check daily | Rationale: Monitoring I&Os provides vital information regarding the patient’s fluid status. Accurate tracking helps identify potential fluid imbalances early, allowing for timely interventions to prevent complications. (Doenges, Moorhouse, & Murr, 2022)Monitoring for clinical signs of electrolyte imbalances is crucial for early identification and intervention. Symptoms such as muscle cramps, weakness, irregular heartbeats, or confusion can indicate imbalances that may require immediate treatment. By regularly assessing the patient, nurses can perform interventions (Doenges, Moorhouse, & Murr, 2022)Regular laboratory assessments help detect electrolyte imbalances and renal function issues early. This allows for prompt interventions. (Doenges, Moorhouse, & Murr, 2022)Maintaining adequate hydration is essential for optimal physiological function and recovery. Encouraging oral intake, while considering the patient’s specific restrictions, helps prevent dehydration and promotes electrolyte balance. . (Doenges, Moorhouse, & Murr, 2022)Regular assessment for signs of dehydration helps in the early identification of fluid imbalances. (Doenges, Moorhouse, & Murr, 2022) |
| Evaluation: Accurate I&O is recorded and stable, Lab values show stable levels within normal limits, no signs of electrolyte imbalance are noted, patient can verbalize understanding of dietary restrictions and demonstrates compliance. | |
CONCEPT MAP FORM
| Problem # and Nursing Diagnosis: Ineffective Tissue Perfusion General Goal: The patient will have improved tissue perfusion | |
| Expected Outcome: The patient will have stable vital signs and improved hemoglobin levels. | |
| Nursing Interventions: Monitor vital signs every 4 hours focusing on blood pressure, heart rate and oxygen saturation Assess capillary refill in extremities every 4 hours when checking vital signs Encourage adequate hydration as tolerated Educate the patient on lifestyle modifications that promote good circulationPosition the patient to enhance venous return (e.g., elevate legs). | Rationale: Monitoring vital signs provides essential information regarding the patient’s status. Blood pressure and heart rate can indicate changes in tissue perfusion hypotension and tachycardia may suggest inadequate perfusion. Oxygen saturation levels also reflect the adequacy of oxygen delivery to tissues. (Doenges, Moorhouse, & Murr, 2022)Capillary refill time is a quick and effective indicator of peripheral perfusion. A refill time of more than 2 seconds or cool extremities may indicate poor perfusion. (Falotico et al., 2020) adequate hydration is vital for maintaining blood volume and promoting effective tissue perfusion. Encouraging fluid intake can help perfusion (Falotico et al., 2020) Education on lifestyle modifications empowers patients to take an active role in maintaining their circulatory health . (Doenges, Moorhouse, & Murr, 2022)Elevating the legs can facilitate venous return to the heart, especially in patients with peripheral vascular issues or edema. Improved venous return helps increase cardiac output and enhances tissue perfusion. (Doenges, Moorhouse, & Murr, 2022) |
| Evaluation: Vital signs remain in normal limits for patient, capillary refill is normal for patient or less than 2 seconds, patient is meeting daily fluid intake goals, patient reports improved comfort. | |
Resources
Seidelman JL, Mantyh CR, Anderson DJ. Surgical Site Infection Prevention: A Review. JAMA. 2023;329(3):244–252. doi:10.1001/jama.2022.24075
Nguyen, D. B., Arduino, M. J., & Patel, P. R. (2019). Hemodialysis-Associated Infections. Chronic Kidney Disease, Dialysis, and Transplantation, 389–410.e8. https://doi.org/10.1016/B978-0-323-52978-5.00025-2
Hegarty, J., Howson, V., Wills, T., Creedon, S. A., Mc Cluskey, P., Lane, A., Connolly, A., Walshe, N., Noonan, B., Guidera, F., Gallagher, A. G., & Murphy, S. (2019). Acute surgical wound-dressing procedure: Description of the steps involved in the development and validation of an observational metric. International wound journal, 16(3), 641–648. https://doi.org/10.1111/iwj.13072
Erdek, F. O., Gozutok, C. K., Merih, Y. D., & Aliogulları, A. (2017). The effects of training inpatients and their relatives about infection control measures and subsequent rate of infection. Northern clinics of Istanbul, 4(1), 29–35. https://doi.org/10.14744/nci.2016.40316
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2022). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales (16th ed.). F.A. Davis. ISBN 9781719643078.
Spampinato, S. F., Caruso, G. I., De Pasquale, R., Sortino, M. A., & Merlo, S. (2020). The Treatment of Impaired Wound Healing in Diabetes: Looking among Old Drugs. Pharmaceuticals (Basel, Switzerland), 13(4), 60. https://doi.org/10.3390/ph13040060
Bolton Saghdaoui, L., Lampridou, S., Racaru, S., Davies, A. H., & Wells, M. (2023). Healthcare interventions to aid patient self-management of lower limb wounds: A systematic scoping review. International wound journal, 20(4), 1304–1315. https://doi.org/10.1111/iwj.13969
Falotico, J. M., Shinozaki, K., Saeki, K., & Becker, L. B. (2020). Advances in the Approaches Using Peripheral Perfusion for Monitoring Hemodynamic Status. Frontiers in medicine, 7, 614326. https://doi.org/10.3389/fmed.2020.614326
