Mind Map #1

Mind Map #1

1. Admitting Diagnosis

   • Fever
     • Respiratory Distress
       • dyspnea w/ exertion
       • Recurrent Hypercapnia
     • Low BP
   • Previous Medical History
     • List of Problems
       • New Problems
         • Generalized Edema
         • Low Blood Pressure
         • Fever
         • Respiratory Failure
         • Elevated Heart Rate
         • Anemia secondary to CKD
       • Historic Problems
         • Depression
         • Sleep Apnea
         • Essential Hypertension
         • Congenital Abnormality of the Lower Limbs
         • Morbid Obesity, Unspecified
         • Diabetes: Type 2
           • No Accucheck
         • End Stage Renal Disease
         • Hx of Infxn due to MRO
         • Fournier's Gangrene
         • Neuropathy
         • Dyslipidemia
         • BPH w. obstruction/lower urinary tract problems
         • Super Morbid Obesity
     • Previous Surgeries
       • Suprapubic Catheter
       • R Subclavian Dialysis Catheter Placement
       • PEG Tube Placement
       • Tracheostomy
       • Debridement of Fournier's Gangrene
     • Medications
       • Scheduled
         • Famotidine
           • standard ICU drugs to prevent pressure ulcers; also tx GERD
             • Watch out for seizures in renal disease pts and pneumonia side effect
         • Folic Acid
         • Heparin 5,000 units
           • Prevent DVT/Thrombi; Watch out for hematuria, hemorrhagin; anemia, and/or anaphylaxis
         • midodrine
           • Vasoconstriction for increasing BP; contraindicated for cardiac disease and urine retention or renal impairment
         • sevelamer carbonate
           • Decreases serum phosphate in patients with end-stage renal disease without the risk of increasing serum calcium levels
         • tobramycin
           • Bacteriacidal; contraindicated to aminoglycasides
         • Vitamin B complex w. C/ folic acid tab
         • Neo-Synephrine
           • Used to increase blood pressure
         • Albuterol
           • Bronchodilator: Watch for bronchospasm
         • Insulin: Reglan
           • For Diabetes
         • Darrbepoetin alfa
           • Decreased anemia with increased RBCs
         • Renvela
       • PRN
         • Acetaminophen
           • PRN: mild to moderate pain: Do not use w/ children, GI Bleeds, renal failure pts;
         • Bisacodyl
           • PRN: Constipation; warnings similar to docusate + abdominal pain, appendicitis, or hepatitis
         • diphenhydramine
           • PRN itching/mild allergic reactions; watch for anaphylactic reaction
         • Docusate
           • PRN: Constipation: Do not give if fecal impaction suspected or n/v
         • Zofran
           • PRN N/V: watch for bronchospasm
   • Labs and Diagnostic Values
     • Metabolic Panel
       • BUN 55 mg/dL
       • Glucose 163 mg/dL
       • Creatinine 3.9 mg/dL
     • Blood Panel
       • WBC 12.9 x 10^3 (High)
       • RBC 2.72 x 10^6
       • Hgb 7.8 gm/dL
       • HCT 27%
       • MCV 99 fl
       • RDW 16.1 %
       • MCHC 28.9 gm/dL
     • C. Diff Negative
     • Positive MRSA in Urine
       • Contact Precautions
     • Pseudomonas in Sputum
   • Treatments
     • medications administration for Fever
     • Tracheostomy Care/Suctioning
     • Daily Weights
     • Monitoring vitals; q15min
     • Nutritional Plan
       • Fluid Restriction 1500ml
       • Dialysis Appropriate Diet
     • medications for increasing blood pressure
     • Daily hemodialysis
     • Turn Pt every 2 hrs
     • temp readings q4hrs
     • Antibiotic tx for poss sepsis/pneumonia
     • Repeating chest xrays
     • Vent at night; 40%
     • Bed/Bath Care
   • Nursing Diagnosis
     • Dx #1: Decreased cardiac output related to decreased preload as evidenced by low blood pressure
     • Dx #2: Ineffective airway clearance related to increased secretions as evidenced by tracheostomy management
   • Head to Toe Assessment
     • EENT
       • 3mm Pupils
       • Cardinal Gazes ✔
       • Whisper Test ✔
       • Oral Mucosa moist and pink
       • Poor Dentition
       • PERRLA
     • Neurological Assessment
       • Oriented x3
       • Pt Denies pain at this time
       • Grip Strength ✔
       • Weakness of lower extremities; congenital defects of lower extremities
     • Respiratory
       • Coarse breath sounds; whitish secretions removed from Trach
       • Dyspnea
       • Tracheostomy
     • Cardiac
       • Heart Rate Regular
       • Capillary Refill: < 3 sec
       • Pedal Pulse: +2
       • Carotid, Radial Pulse +3
     • Skin
       • IV Left Forearm
       • Turgor ✔
       • Small 1 cm ulceration about the anterior R ankle
       • small 1 cm abrasion on R pinky toe
       • Trace +1 lower extremity edema
       • R Subclavian VAS cath
       • Tripple PIC lumen
       • PEG Tube
       • Traacheostomy
       • Left ankle stage II ulcer wound
     • Abdomen
       • Firm
       • Normoactive sounds
       • Obese; distended
       • BM x 2; Normal
     • Spiritual/Psychosocial
       • Daily visits from family
       • Father died day before shift start
       • Depression
       • Asked for visit from Chaplain
         • Religion: Other
     • Vitals Trend
       • HR: min-79 . max-97
       • BP: min88/44 . Max-114/62
       • RR: min-13 . Max-31
       • SaO2%: min-90 . max-100
       • Temp: min-36.9 C . Max-37.2 C

2. Patient Demographics

   • Initals: KV, Male
   • Status: Full Code
   • Allergies
     • Ciprofloxacin, Hydrolazine, Iodine, Lisinopril, Sulfradrugs
     • Tomatoes, Nuts, Chocolate, Shellfish
   • Religion: Other
   • Race: White
     • Ethnicity: Not hispanic or Latino
       • Language: English
   • Weight: 268.5 lbs
     • BMI: 46.1