Question

need help with the map

PN 200 Fundamentals of Nursing II Concept Map: Care of the Surgical Patient: Acute Pancreatitis Betty Boop is a 72 y/o woman is admitted to your unit from the Emergency Room with the chief complaint of constant, severe abdominal and lower back pain for two days and shortness of breath over the past 24 hours. She tells you "I've had to rest four or five times just walking back to the house from my yard storage shed. It's gotten real hard to manage by myself" A niece stopped by to visit the patient and insisted she go to the hospital to be evaluated. Betty Boop has not received medical care of any kind. She lives by herself in a remote area of the county off of a dirt road in rural Florida. She is restless, nauseated, and in pain. Everything around her in the hospital is new and frightening to her. Vital signs are 108/72, 128, 30, 96.8. O2 sats are 84% and was started on O2 at 2L/min. She is admitted to your unit at 7PM. Ms. Boop arrives on your unit. As she is getting into bed, you notice that her eyes are very wide and she is looking all around. She seems totally overwhelmed in response to the nurse's explanation of how to operate the bed. You complete your assessment and note the following abnormalities: restlessness: prefers to sit on the edge of the bed leaning forward and tightly clutching her purse. States that the pain has decreased ever since that nurse jabbed me with that needle downstairs." Skin is cool, diaphoretic, and pale. Heart rate is 126 and irregular and tacky. Peripheral pulses weakly palpable X 4 extremities. Respirations are rapid at 26 /min but unlabored on O2 at 2L/min via nasal cannula. SaO2 is 85%, breath sounds absent at the base of the left lower quadrant posterior. Reports marked nausea without emesis. Bowel sounds hypoactive all 4 quadrants. Abdomen distended and exquisitely tender throughout the abdomen to light palpation, guarding noted. She has not voided since arriving on the unit but states "I have made less water than usual." Further assessment reveals poor skin turgor, dry mucus membranes, and mild sclera jaundice. Ms. Boop's admission labs return Na 148 WBC 17,200 AMYLASE 200 4.2 Hgb 12.5 Hct. 38% Lipase 375 114 LDH HCO3 98 Platelets 308 AST BUN ALT Creatinine 1.0 Glucose 185 CI 160 54 26 46 Reviewed 1/20

Answer 1

Acute pancreatitis

Nursing diagnosis Acute pain in abdomen related to inflammatory process of pancreatic gland as evidenced verbalisation, abnormal vital signs, raised laboratory values	Nursing diagnosis Ineffective breathing pattern related to decreased lung function as evidenced by decreased oxygen saturation
Intervention Assess the level of pain, to make appropriate plan of care Administer analgesics as per order to relieve pain Keep patient NBM as per order,this can reduce the gastric action and decrease nause and associated pain and workload of pancreas Provide diversional therapy ,to feel relaxed	Intervention Monitor vital signs, baseline data to plan for a care Administer oxygen via nasal cannula to maintain normal oxygen saturation Administer bronchodilator as per order Teach breathing exercise
Positive outcomes The patient will have reduced pain	Positive outcomes The patient will be able to breath easily
Negative outcomes Risk for complications is high	Negative outcomes Acid base imbalance can occur
Evaluation The patient is able to do activities by self with no fear and pain	Evaluation The patient maintain an oxygen saturation above 90%,normal breath rate