Patient Ihuman Concept Map
An Ihuman concept map is a layout plan that outlines a patient's history either by providing a table, or a storyline on a patient's condition. For students struggling to interpret information based on medical interviews, they help to provide a photographic idea of the patient's condition and review. Below is a concept map for JMRP.
Patient Initials: JMRP (JP) Patient Age: 55 Gender: Male
Medical Diagnoses
Chief complaint: Severe gastrointestinal issues for the last 24 hours Rule out small bowel obstruction with severe gastrointestinal pain
Pathophysiology Review
A small bowel obstruction is a blockage in the small intestine. This blockage can be either partial or totally that comes from a buildup of the substances of stool, fluid, and gas that are not properly leaving the body, causing a buildup in the small intestine. According to Smith, Kashyap, and Nehring the normal physiology of a small bowel obstruction of the small intestine consists of the digestion of food and the absorption of nutrients, these lead to abdominal pain, nausea, vomiting, constipation, obstipation, and distention in the abdomen.
Assessment Data
JP is a 55-year-old Hispanic male that was directly admitted into the hospital for a rule out small bowel obstruction. He complains of severe pain rating it at an 8/10 according to a pain scale, and gastrointestinal issues including not being able to pass gas or have a bowel movement in the last 24 hours. He currently has an 18-gauge intravenous needle placed on his right antecubital that has running Lactated Ringer fluids. JP is alert and oriented, times four, person, place, time, and situation. Looking at his skin he has no visible signs of redness or lesion, he is diaphoretic and warm to the touch, his skin is appropriate to ethnicity with pink undertones.
He has a good skin turgor that recoils within two second and the capillary refills in his nail bed in less than three second. His vitals for the leaving nurse were, temperature 99.0 F that later increased to 101.5 F, pulse 105 bpm that decreased to 102bpm, respirations remained 28 breaths per minute at both checks along with 98% saturation in his oxygen. JP reported a 4/10 pain according to the numerical pain scale that later increased to 8/10 pain. After checking the vitals, I did a complete head to toe. Starting with the head, while doing inspection there were no visible signs of infestation, edema, deformities, scar, rashes, or lesions after palpitation there were no signs of lumps or mass. His eyes have no ptosis, erythema, or swelling, the conjunctiva is noted pink, moist and intact and the sclera is white. Both ears are proportional to the body with no note of swelling, redness, or exudate. The patient JP is responding which indicates hearing is intact, palpitations of the ears indicated no signs of tenderness in front or behind the ear. While inspecting the patient's nose, it is midline and proportional to the body, the patient has a nasogastric (NG) tube placed that is suctioning at a low intermittent pressure with no signs of drainage coming from the nasal cavity. His tongue upon inspection is pink moist and intact with no indication of swelling, redness or lesions he has no indication or slurred speech or issues with swallowing.
Looking at the patient's neck there are no signs of bulging, mass, or lesions. His jugular vein is not distended and is not seen, the trachea is midline to the body with no deviations noted when asked to move his head in different directions that patient showed to have full range of motion with 5/5 strength against resistance. For the cardiovascular system, there with inspection there were no signs of bulging palpitations from the heart, there was no notable tenderness on the anterior part of the body S1 and S2 were heard, no other sounds heard, no murmur. When inspecting the patient back there were no signs of lesion, redness, or swelling, no tenderness noted with palpation, vibration felt throughout when auscultating the lungs clear and vesicular lung sounds heard throughout, his respirations are noted 28 breaths per minute irregular, unlabored. Looking at his abdomen, there was noted a distension also he has a healed stoma located on the left lower quadrant of his abdomen. The healed stoma has edematous tissue surrounding the stoma. With auscultation of the abdomen hypoactive bowel sound heard throughout all four quadrants.
1st Nursing Diagnosis
Blockage in the intestine is related to small bowel obstruction as evidenced by deep cramping abdominal pain, hypoactive bowel sounds and absence of bowel movement in over 24 hours.
Measurable Expected Outcome
The patient will have some relief from by helping to decrease the blockage in the small intestine with the use of a therapeutic enema and placing the patient on an nothing by mouth (NPO) diet to allow for the rest and gastrointestinal movement.
| Implementation | Evaluation |
| 1. Provide therapeutic enemas | By giving a therapeutic enema, depending on the obstruction this can help to relieve the impaction that a patient has (Crawford, 2018). The outcomes for this would include some alleviation in the patient’s abdomen and assist with breakdown of the substances that are in the small intestine. As the nurse we educate the patient in cramping and discomfort from using this. |
| 2. Place the patient on an NPO diet and placed on IV fluids | By placing the patient on a nothing by mouth diet this allows for the patient's GI system to relax to see if the obstruction can clear on its own. While the patient is on this NPO diet they should be given added fluids. |
2nd Nursing Diagnosis
Risk for pain related to small bowel obstruction as evidenced by a stated 8/10 deep cramping in abdomen and elevated vital signs.
Measurable Expected Outcome
The patient will have his pain under control according to the 1-10 pain scale by dispensing pain medication as needed and placing a nasogastric tube in the nose to help alleviate some of the pain in the pain the patient is experiencing.
| Implementation | Evaluation |
| 1. Give medication to help reduce pain by asking OLD CARTS and checking the severity of pain | Opioid pain medication can be given to alleviate pain in the abdomen, but due to opioids leading to constipation it is advised to also give a laxative or stool softer (Crawford, 2018). The patient reports a decrease in pain. He first reported a 4/10 and then 8/10 pain medication were given. |
| 2. Place a nasogastric (NG) tube to depress some of the gas and fluids in the stomach. | “A tube is inserted through the nose and into the stomach to remove fluids and gas, which can promptly relieve pain and pressure. It will be left in place until the intestines are working well” (Lucey and Mahnke, 2018). The expected outcome for using the NG tube is to allow for the secretions from that stomach to be drained. It was reported 225 drained |
3rd Nursing Diagnosis
Risk of depression related to multiple hospitalization procedures as evidenced by history of colorectal cancer with a surgery of a total colectomy with colostomy and lack of family support.
Measurable Expected Outcome
The patient will be assessed by the social worker and assessed for depression while in the hospital to ensure a safe recovery when going home.
| Implementation | Evaluation |
| 1. Social Workers assessment of the patient | JP expresses issues outside of the hospital to help promote a safe recovery and minimize the chances of readmission a social worker can provide the at-home resources that JP may need for recovery. |
| 2. Discuss outside resources that can help the patient in recovery processes | JP states that he smokes, uses recreational drugs, and drinks four beers a day. As the nurse we want to ensure that he was not drinking as a sign of depression. By using a Depression scale we can determine whether or not he is depressed. |
Reflection
I appreciate doing this RUA paper because it allowed me to see how to work through a patient case study and creating a care plan for the patient. For the nursing care plan we assess, diagnose, explain outcomes, think of interventions, explain the rationales for the nursing interventions, and evaluate the results. For JP, he was brought in for a rule out of a small bowel obstruction, he presented with systems of severe gastrointestinal issues and not being able to pass gas or have a bowel movement in the last 24 hours. In this care plan the three nursing diagnoses I used were: (1) Blockage in the intestine is related to small bowel obstruction as evidenced by deep cramping abdominal pain, hypoactive bowel sounds and absence of bowel movement in over 24 hours. (2) Risk for pain related to small bowel obstruction as evidenced by a stated 8/10 deep cramping in abdomen and elevated vital signs. (3) Risk of depression related to multiple hospitalization procedures as evidenced by history of colorectal cancer with a surgery of a total colectomy with colostomy and lack of family support.
JP was admitted to the hospital to rule out a small bowel obstruction; the three nursing diagnoses that I chose are all related to help promote a healthier outcome for him and his care. For the first nursing diagnosis explains what the small bowel obstruction is and the symptoms
that JP is experiencing. The second nursing diagnosis I chose to do addressed one of the main symptoms that brought him into the hospital. And then finally for the third diagnosis I looked at the risk of him becoming depressed, JP is 55 years old and has had cancer and surgery with no family or real support outside of the hospital he also has a history of alcohol consumption and smoking providing him with resources can help promote the quality of life that he needs for recovery.
Safety
Soe safety concerns that we have for this patient are his movement while connected to the NG tube. The patient is younger and can get in and out of the bed as tolerated, meaning he can go to and from the bathroom. For this patient we want to ensure the tubing that he is connected to is either able to reach where he needs to go or staffing assistants should be in the room to help him. Another safety concern that we have for this patient is skin breakdown, he is currently considered a mild risk according to Braden Skin Assessment to prevent his risk from increasing reminding the patient to move while in the bed.
Communication
The patient and I were able to communicate while I was getting the history portion for him. Although he was able to communicate back, I noticed that his answers were short, and to the point. For example when I asked him how he was doing he replied “It hurt” instead of responding “I am hurting” and the location of where he was in pain. I was able to get the basic information needed to know information. One issue that could have hindered him from not wanting to speak as much would be the reported pain that he was in.
Infection Control
One of the main things that we worry about with this patient is infection. The patient has a placed nasogastric tube and with that comes the added risk of infection. “The contamination of enteral feed can often be overlooked as a source of bacterial infection. Enteral feeds can become contaminated in a variety of different ways. Most often infections result in extended lengths of stay in hospital and patients also need additional therapies and treatments in order to resolve these infections” (Malhi, 2017). Since the patient did have a report of elevated white blood cells and a reported fever to help decrease the risk of infection teaching the patient how to properly clean and provide a sterile environment. Another thing that we as the staff must watch for is the wound that he has, his stoma, we want to make sure that it does not become infected to do that consulting a wound nurse to look at the stoma and evaluate it helps to ensure that it is not becoming or is infected.
References
Crawford, J. (2018 Dec. 19). Medical News Today. Bowel Obstruction: Symptoms, Causes, Treatment, and Diet. https://www.medicalnewstoday.com/articles/324037
Lucey JR, Mahnke D. (2018 Nov. 1). Health Library: Evidence-Based Information. Small Bowel Obstruction.https://chamberlainuniversity.idm.oclc.org/login?
url=https://search.ebscohost.com/login.aspx?direct=true&db=nup&AN=2009867240&site=eds-live&scope=site
Malhi H. (2017). Enteral tube feeding: using good practice to prevent infection. British journal of nursing (Mark Allen Publishing), 26(1), 8–14. https://doi.org/10.12968/bjon.2017.26.1.8
Smith DA, Kashyap S, Nehring (2020 Aug. 10). NCBI: StatPearls. SM. Bowel Obstruction. https://www.ncbi.nlm.nih.gov/books/NBK441975/
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