Low Sodium Diet Concept Map Complete

Erickson’s Developmental Stage Related to pt. & Cite References (1) According to Erikson’s Developmental Stage theory, the Pt relates to stage 6 – Young Adulthood (19 to 40 years). Young adults need to form intimate, loving relationships with other people. Success leads to strong relationships, while failure results in loneliness and isolation. This stage covers the period of early adulthood when people are exploring personal relationships. each step builds on skills learned in previous steps. Erikson believed that a strong sense of personal identity was important for developing intimate relationships. Since the Pt is a single mother with 2 children living with her parents indicates that she is not been able to form a intimate, loving relationship which can lead to isolation (Cherry, 2020). Patient Education (In Pt.) & Discharge Planning (home needs) Educate Pt about following a low sodium diet. Encourage patient to read food labels and avoid foods high in sodium (e.g., bacon, luncheon meats, hot dogs, canned soups,etc.) (Nurseslabs, 2021) Collaborate with dietitian as indicated. - Nutritional consult may be beneficial in determining individual needs/dietary plan due to prediabetes, GDM diagnosis and preeclampsia (Nurseslabs,2021) Educate patient and family members or significant others on home monitoring/day-care program, as appropriate - Some mildly hypertensive patients without proteinuria may be managed on an outpatient basis if adequate surveillance and support is provided and the patient/family actively participates in the treatment regimen (Nurseslabs,2021) Pediatrician and neonatal intensive care nurse are needed in delivery room for both scheduled and emergency cesarean births - Owing to underlying maternal condition(s) and alternative birth process, infant may be preterm or may experience altered responses, necessitating immediate care or resuscitation (Nurseslabs,2021) Educate Pt about signs and symptoms of infection such as elevated temperature, redness, warmth to touch and abnormal discharge from incision (Nurseslabs,2021). Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Pt is a L&D Nurse, works night shift - every other week. Hispanic ethnicity. Did not report any religion. Has a BSN,. Single mother, living with parents and brother, has access to food, health care and medications. Chief Complaint Contractions, rupture of membrane or bleeding. Severe headache, Blurry vision, nausea, vomiting, High blood pressure (170/110) Patient Information (1) Diagnostic Test/ Lab Results with dates and Normal Ranges (3) Test ALT AMYLASE AST BUN RBC WBC’s CREATINE GFR LIPASE PLATELETS Norms <=54U /L <=100 U/L <=30U /L <=18m g/dL 4.205.40mi ll/mcl 4.011.0x1 000/ mcl <=1.10 mg/dL <=60m l/min/ bsa <=58U /L 130400X1 000/ MCl Date Name: C.M. Age:27 Current Value 18 U/L Height/Weight:5.5 H 165 06/05/2 0 06/06/2 0 06/05/2 0 06/05/2 0 06/05/2 0 5.13mill /mcl 06/05/2 0 8.6x100 0/mcl Name Dose RT Freq. MOA RN Considerations 06/05/2 0 06/05/2 0 0.58mg/ dL >120ml/ min/bsa Lantus 10 units Sub Q Once daily 06/05/2 0 06/05/2 0 33U/L works by promoting movement of sugar from blood into body tissues and also stops sugar production in liver (Durham & Chapman, 2019) directly relaxes the arteriolar smooth muscle but not venous smooth muscle which is responsible for vasoconstriction Assess VS and contraindications Inspect skin area for injection areas that are bruised,hickened, or scarred, could interfere with insulin absorption 5-10 mg IV over 2 min and q 20 min until target BP reached. Do not exceed 25mg in 24hrs (Durham & Chapman,2019) 48U/L Allergies: Shrimp ,cats, horses (hives, eye swelling, itchy throat) 17U/L Gestational Age: 38/2 9mg/dL Admitting Diagnosis NSVD, or C-Section Medical Conditions Preeclampsia, Non-reassuring Fetal Status, deep variable decelerations, C-section Admitting Dx (Cite References) Medical, Surgical, Social History and OB History Preeclampsia, Non-reassuring FHR, deep variable decelerations, CSection. Preeclampsia – New-onset hypertension after 20 weeks gestation with two blood pressure readings at least 140 mm Hg systolic and or at least 90 mm Hg diastolic taken at least 4 hrs apart. Proteinuria >300mg in 24hrs or new-onset systemic disease including thrombocytopenia, impaired liver function or RUQ/epigastric pain (Durham & Chapman, 2019). Non-reassuring fetal status (NRFS) – Medical term used to describe suspected fetal distress (Durham & Chapman, 2019). Deep Variable Decelerations - Irregular, often jagged dips in the fetal heart rate that look more dramatic than late decelerations. Variable decelerations happen when the baby’s umbilical cord is temporarily compressed (Healthline, 2018). C-Section – also called surgical birth, is an operative procedure in which the fetus is delivered through an incision in the abdominal wall and the uterus (Durham & Chapman, 2019). Medical History Prediabetes (before pregnancy), GDM, preeclampsia Prediabetes – A health condition where the blood sugar levels are higher than normal ,but not enough yet to be diagnosed as diabetes (CDC, 2021). Gestational Diabetes Mellitus (GDM) – Glucose intolerance that does not present prior to pregnancy (Durham & Chapman, 2019). Preeclampsia – Hypertension accompanied by underlying systemic pathology accompanied by proteinuria after 20th week gestation (Durham & Chapman, 2019). Medical Management/ Orders/ Medications & Allergies (2) 253X10 00/MCl Hydralaz ine 510mg IV Q 20 min Onset/ Peak/ Duration (Insulin) Onset 60-70 min Peak – none, duration 24hrs (Nurseslabs, 2021) Surgical History Cholecystectomy (2015) – Surgical removal of the gallbladder (Durham & Chapman, 2019) Unilateral salpingectomy (R) (2018) – Surgical removal of a fallopian tube (Durham & Chapman, 2019) Elimination half-life: 2–8 hours, 7–16 hours ... Onset of action: 5 to 30 min Duration of G4 T1 P1 A2 L2 Social History Pt is a single mother, does not smoke or take any Illicit drugs and drinks 1-2 beers maybe every 2-3 months Obstetric History GTPAL Priority nursing diagnosis #1 Altered Tissue Perfusion (Uteroplacental) Rt interruption of blood flow (progressive vasospasm of spiral arteries) AEB Changes in fetal activity/heart rate – nonreassuring fetal status and deep variable decelerations (Nurselabs, 2021) Vital Signs (4) Temp 38.2 C, P 120 b/min, RR 38, O2 Sat 95% at room air, BP 170/110; Pain 9/10 Nutrition/Hydration (8) Low-carbs diet (GDM) 90% intake. Restricted intake, oliguria Outcome/Goal #1 Pt will achieve and maintain her BP at equal or less than 140/90 prior, during and post surgery (C-section) (Durham & Chapman,2019) Interventions #1 Assess vital signs before medication And 5-10 min after – Labetalol is giving in escalating doses from 2 to 10 min (Durham & Chapman,2019) Monitor FHR - Helps evaluate fetal wellbeing. An elevated FHR may show a compensatory response to hypoxia, prematurity, or abruptio placentae (Nursselabs, 2021) Administer antihypertensive medication – Mg is contraindicated with pulmonary edema(Durham & Chapman,2019) Maintain accurate I&Os – Total fluid intake may be restricted to <2000 mL/24hrs (Durham & Chapman,2019) Educate Pt and family about disease process and plan of care (Durham & Chapman,2019) Potential Complications/ at risk for 1 -Risk for Infection Rt Invasive procedure, break in the skin, rupture of amniotic membranes (Nurseslabs, 2021) 2 – Risk for Impaired Fetal Gas Exchange Rt altered blood flow to placenta and/or through umbilical cord (Nurseslabs, 2021) Integumentary (12) Pt’s skin is intact, warm to touch, moist, even color, pink undertone, +3 pitting edema Neurological (5) Pt A&O+4. Pt is able to articulate clearly, Pt reports blurry vision, and light sensitivity, no hearing problems and 9/10 pain at the time of assessment GI (9) Nausea, vomiting Endocrine (13) GDM No thyroid issues Assessment/ Evaluation #1 Goal met , Pt BP decreased to 140/90 and it was maintain throughout my shift (prior,during and post-surgery) PC Outcomes/Goal 1 - Pt is free from infection during hospital stay (Nurseslabs,2021) 2 - Patient reduces frequency of or prolonged variable deceleratio prior the surgery (Nurseslabs,2021) Cardiovascular (6) HR 120, B/P 170/110 S1 and S2 heard with no additional/abnormal sounds GU (10) No pain, burning when urination, oliguria (<34mL/hr), normal order and color in urine Psychosocial (14) Pt is anxious about health condition, Pt shows some agitation, Pt presents appropriate personal hygiene Respiratory (7) Pt reports SOB,. Pt presents diminished breath sounds with crackles, symmetrical respiration expansion anteriorly and posteriorly Rest/ Exercise (11) Pt is at bed rest due to severe headache (fall risk), FHR monitoring Misc. (Ht/Wt) Ht. 5.5ft Wt 165lb Musculoskeletal Pt’s upper and lower extremities present ROM according to age, normal symmetry, no joint swelling or stiffness, normal muscle strength Assessment/ Evaluation #2 Goal partially met, Pt’s pitting edema decreased from +3 to +2, Pt was free of nausea and vomiting during my shift (prior, during, and post-surgery) PC Interventions 1 -Know history for preexisting conditions or risk factors. Note time of rupture of membranes. - History of diabetes or hemorrhage increase chances of infection and poor wound healing (Nurseslabs,2021) 1 -Assess signs and symptoms of infection - Rupture of membranes occurring 24 hr before the surgery may result in chorioamnionitis prior to surgical intervention and may impair wound healing (Nurseslabs,2021) 2 - Monitor fetal heart response to preoperative medications or regional anesthesia. - Narcotics normally reduce FHR variability and may necessitate administration of naloxone (Narcan) following delivery to reverse narcotic-induced respiratory depression (Nurseslabs, 2021) 2 -Give supplemental oxygen to mother via mask - Maximizes oxygen available for placental uptake (Nurseslabs,2021) Priority nursing diagnosis #2 Deficient Fluid Volume Rt plasma protein loss AEB edema formation (+3 pitting edema) (Nurselabs,2021) Outcome/Goal #2 Patient is free of signs of generalized edema (cerebral symptoms, dyspnea, nausea/vomiting) prior, during and post-surgery (Nurselabs, 2021) Interventions # 2 Monitor intake and output. Note urine color, and measure specific gravity as indicated Urine output is a sensitive indicator of circulatory blood volume. Oliguria and specific gravity of 1.040 indicate severe hypovolemia and kidney involvement (Nurselabs,2021) Assess lung sounds and respiratory rate/effort Dyspnea and crackles may mean pulmonary dema, which needs immediate treatment Nurselabs,2021) Insert indwelling catheter if kidney output is reduced or is less than 50 ml/hr - Allows more accurate monitoring of output/renal perfusion (Nurselabs,2021). Monitor serum uric acid and creatinine levels, and BUN. - Elevated levels, especially of uric acid, indicate impaired kidney function, worsening of maternal condition, and poor fetal (Nurselabs 2021) outcome PC Evaluation Plan 1 - Goal met, Pt was free from infection during her hospital stay and at discharge 2 - Goal met, FHR was maintained WNL