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Concept Map Er

CONCEPT MAP

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Doreen Claire
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30 views

Concept Map Er

CONCEPT MAP

Uploaded by

Doreen Claire
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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*access to firearms *intentional violence Open wounds, entry and exit,

Fainting
with shape of a bullet tip
*substance misuse including
alcohol, mental health
problems Fast heart rate but with weak
pulseskin; with Weakness
Cold clammy
Changes in conciousness
*fire arm laws capillary refill of 5 seconds;
with blue lips
Shallow rapid breathing with
*social and economic Excessive bleeding
chest pain
differences
Profuse sweating

COMPLETE BLOOD COUNT COAGULATION SCREENING TESTS

*WBC, *Neutrophil, *Lymphocytes, *Activated partial Thromboplastin Time, *Bleeding Time

*Monocytes, *Eosinophil, *Platelet *Partial Thromboplastic Time, *Prothrombin Time

COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT COMPLETE BLOOD COUNT

Hemoglobin- 95.0 Hematocrit- 30% RBC- 3.1 RBC- 3.1


Deficient fluid volume related to active fluid Risk of infection related to presence of incision Anxiety related to stress to hospitalization as
loss (bleeding) secondary to gunshot wound wound at the abdomen from previous evidenced by the patient's report.
on the right upper quadrant of the abdomen exploratory laparotomy.
and stabbed wound on the left supraclavicular
area.
Monitored  vital signs. Helped to determine the source of anxiety and
the level of anxiety.
Monitored BP for orthostatic changes (changes
seen when changing from a supine to a
standing position). Assessed for signs and symptoms of infection
Provided support by staying with the patient
specially, temperature, draining of pus in speaking slowly, calming and conveying a
incision and redness. sense of caring and empathy.
Assessed the HR, BP, and pulse pressure.
Use direct intra-arterial monitoring as ordered.
Maintained aseptic technique when changing Encouraged to verbalize feelings and
dressing and cleaning of wounds. expressed emotions.
Assessed for changes in the level of
consciousness.
Keep the area around the wound clean and Encouraged to do other activities such as
dry. watching movies or listening to musics.
Monitored for possible sources of fluid loss.

Administered antibiotics as prescribed.


Assessed the client’s skin turgor and mucous Educated about eating a well-balanced diet.
membranes for signs of dehydration.
Emphasized the importance of hand washing.

Monitored the client’s intake and output. Supplenex (x8hrs OD)


Emphasized the necessity of taking antibiotics
as ordered.
Cefuroxime (750mg IV q 8 º)
If trauma has occurred, evaluate and Ranitidine (5mg IV q 8 º)
document the extent of the client’s injuries; use
a primary survey (or another consistent survey
method) or ABCs: airway with cervical spine
Ketorolac (30mg IV q 8 º)
control, breathing, and circulation.

Tranexamic acid (2 ml IV)


Performed a secondary survey after all life-
threatening injuries are ruled out or treated.
Dopamine

Monitored the client’s central venous pressure


(CVP), pulmonary artery diastolic pressure IVF (.9% PNSS)
(PADP), pulmonary capillary wedge pressure,
and cardiac output/cardiac index.

Monitored coagulation studies, including INR,


prothrombin time, partial thromboplastin time,
fibrinogen, fibrin split products, and platelet
count as ordered.

Initiated IV therapy. Start two shorter, large-


bore peripheral IV lines.

If hypovolemia is a result of severe diarrhea or


vomiting, administer antidiarrheal or antiemetic
medications as prescribed, in addition to IV
fluids.

Prepared to administer a bolus of 1 to 2 L of IV


fluids as ordered. Use crystalloid solutions for
adequate fluid and electrolyte balance.
Administered blood products (e.g., packed red
blood cells, fresh frozen plasma, platelets) as
prescribed. Transfuse the client with whole
blood-packed red blood cells.

Encouraged significant others to increase oral


fluid intake if the patient is able to do so.

LEGEND:

RISK FACTORS

SIGNS AND SYMPTOMS

LAB RESULTS BLACK FONT COLOR WHITE FONT COLOR


(NORMAL RESULTS) (ABNORMAL RESULTS)

NURSING DIAGNOSIS/ES

MEDICATIONS AND OR PROCEDURES

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