MED SURGE

NURS 121L-A Rev. 2-20

 

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

 

Medical History

 

Breast cancer

 

 

Surgical History

 

 

No previous surgeries

 

Social History

 

Patient is married, lves with her husband and has two grown children and have accompanied her.

 

 

Medical Management/ Orders/ Medications & Allergies (2)

 

Name

Dose

RT

Freq.

MOA

RN Considerations

Onset/Peak/Duration

(Insulin)

Valium

10 mg

IV

1½ hours before surgery

Reduce apprehension

Assess blood pressure, pulse and respiration

NA

 

NURS 121L-A Concept Map

 

Student Name:

Instructor:

 

 

 

Patient Education (In Pt.) & Discharge Planning (home needs )

 

 

 

Full assessment of patient.

Provide for physical and thermal comfort.

Therapeutic communication.

Begin post op education for day one.

Notify family as to when they may come and visit.

 

 

Patient Information

(1)

Name: V.G

Age: 52

Gender: F

Code Status: Full Code

DPOA: Husband

Living Will: Completed

 

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14)

The patient is white and is provided support by her husband and her two grown children

 

Chief Complaint

 

Preoperative care for surgical operation

 

 

 

Admitting Diagnosis

 

Breast Cancer

 

Erickson’s Developmental Stage Related to pt. & Cite References (1)

 

 

Diagnostic Test/ Lab Results with dates and Normal Ranges (3)

 

 

Test

Norms

Date

 

Current Value

 

PC Outcomes/Goal

 

The patient demonstrates understanding of plan to heal skin and prevent reinjury

 

Priority nursing diagnosis #2

 

Impaired physical mobility

 

Respiratory (7)

Oxygen: Room Air

Bipap/Cpap: N/A

Trach: N/A

Vent: N/A

O2 Saturation: 98 %

Lund Sounds: Clear

Vital Signs (4)

 

Temperature 98.3

HR 87

RR 16

BP is 121/74

 

Ht/Wt

Integumentary (12)

Skin intact: warm and dry to touch

Wound: surgical wound; clean and dry

 

 

Assessment/ Evaluation #1

 

Assessment/ Evaluation #2

 

 

PC Interventions

Take and assess Vital signs by automatic B/P Cuff q 15 minutes

 

Talk with her stating surgery in over and she did great.

Allow husband to come into recovery for a quick one minute visit.

Document and prepare to transfer to Surgical ICU

Psychosocial (14)

Patient is cooperative, understands directions , deciosn making is concrete and judgement is appropriate

Cardiovascular (6)

 

Color: pale

Capillary reill: <3 seconds

Peripheral Edema: None

Rhythm: Regular

Endocrine (13)

No Thyroid Disease

No Estrogen Use

No Testosterone use

No steroid use

No diabetes

 

Musculoskeletal

ROM: Active

Mobility Aids: Walker

Gait: Steady

GU (10)

Urine is clear

GI (9)

Bowel sounds are normal

Nutrition/Hydration

(8)

Diet: Regular

feeding method: self

Mucous Membranes: Dry

Skin Turgor: No problem

Rest/ Exercise (11)

Activity: Bed rest

Functional level: Independent

Sleep Patterns: Uninterrupted

Neurological (5)

Orientation: √ Time √ Place √ Person √ Purpose

Normal Sensation

Level of Consciousness: Alert

Coordination: Symmetrical

 

Outcome/Goal #1

Patient will report relived/ controlled pain.

Priority nursing diagnosis #1

Acute pain

 

 

 

 

 

 

 

 

 

 

 

 

Outcome/Goal #2

Pateint verbalizes feeling of increased strength and ability to move

 

 

 

 

 

 

 

 

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Potential Complications/ at risk for Impaired skin integrity

 

 

PC Evaluation Plan

 

Interventions # 2

Therapeutic communication

Validate NPO Status

Encourage to ambulate with assistance to void if needed.

Connect telemetry

Provide a few chairs if possible for her family to also be comfortable

 

Interventions #1

Ask patient to explain to you what procedure she was expecting to have this morning.

If patient statement differs from the surgical consent she has signed, notify surgeon immediately.

Stay with patient for surgeon’s arrival to explain intended surgical procedure

Contact head nurse or supervisor in the OR to evaluate new situation

Procedure is canceled for the day and rescheduled at a later date allowing for new consent.

NURS 121L-A Rev. 2-20