Question: VL. PUTTING IT ALL TOGETHER CONCEPT MAP Draw A Concept Map Identifying What Are RELATIONSHIPS Between The Following? Primary Problem/diagnosis; Pathophysiology Of The Current Problem, Surgical Repair, Other Current Problems; Past Health History, Current Signs And Symptom; Assessment Findings; Labs, V/S, Diagnostics; Potential Impact On Body Systems …

VL. PUTTING IT ALL TOGETHER CONCEPT MAP Draw a concept map identifying what are RELATIONSHIPS between the following? Primary problem/diagnosis; pathophysiology of the current problem, surgical repair, other current problems; past health history, current signs and symptom; assessment findings; labs, V/S, diagnostics; potential impact on body systems if left untreated (Complications); Interventions (l.e. medications, assessments, treatments, teaching). – Use arrows to indicate relationships and the direction of the relationship. What leads to what? Or What causes what? Place a box around data that are current problems, pathophysiology, past health history, S/S, labs, V/S, etc. Place a circle around your interventions that affect or treat each problem, symptom, sign, V/S, lab, etc. Patient Information Chief Informant: Shellfish (causes hives) Boyd Dubois Right hip pain with ambulation Allergies: Family History: Mother, osteoarthritis; father, hypertension Chief Complaint: History of Current Problem: Boyd Dubois is a 58-year-old Caucasian male who presented to my office complaining of right hip pain. Patient reports that the pain has progressively worsened over the past 10 years, affecting his quality of life. He has been treated conservatively with medication in the past for osteoarthritis of the right hip. This treatment had effectively controlled his pain and maintained adequate range of motion in his right hip, but this treatment is no longer working. Past Medical History Contagious Diseases: None Previous illnesses: Osteoarthritis, hypothyroidism, gastroesophageal reflux disease Injuries or Trauma: None Surgical History: Vasectomy Other: Dietary History: Well-balanced diet Social History: Boyd Dubois is married and has two grown sons who live out-of-state. He is a member of the local golf club and is active in his church. Current Medications: 1. Levothyroxine 0.05 mg by mouth daily 2. Pantoprazole 40 mg by mouth daily 3. Glucosamine sulfate 1500 mg by mouth daily 4. Diclofenac sodium 50 mg by mouth 3 times a day 5. Calcium carbonate 1200 mg by mouth daily 6. Acetaminophen 650 mg by mouth 3 times a day Review of Systems HEENT: Integument: No issues No issues Respiratory Denies shortness of breath. No recent respiratory illness. Cardiovascular: Denies chest pain. Exercised regularly until hip pain intensified. No cardiac family history. Sleeps on one pillow. Only able to walk 2 blocks without stopping because of pain. Gastrointestinal: History of reflux disease that is currently well controlled with medication Genitourinary Denies urgency, incomplete stream, or dribbling. Urinates once per night. Musculoskeletal: Right hip with moderate to severe pain per patient report. Progressively worse over the past few years. Neurologic: Numbness and tingling in right foot at times Developmental: No issues Endocrine: Thyroid is well controlled on medication. Sees an endocrinologist once a year. Genitalia No issues. Sexually active with wife. Lymphatic: No issues Physical Exam General: Overall good health, with the exception of becoming more sedentary as a result of right hip pain. Vital Signs Blood pressure 134/82, heart rate 82, respiratory 16, temperature 98.8 F (37.7 C) Integument: Clean, dry, and intact HEENT: Head is symmetric, with no lesions. Pupils equal, round, reactive to light and accommodation. Ears exhibit no drainage. No deviation of nasal septum, trachea midline. No lumps or enlargements noted during palpitation. Cardiovascular: Regular rate and rhythm. S1 S2; no murmurs, rubs, or gallops. Respiratory Adequate depth and rate, chest wall symmetric. Lungs are clear throughout. Genitourinary: Gastrointestinal: Bowel sounds in all 4 quadrants; abdomen is flat and soft. Musculoskeletal: 3/4 muscle strength on extension and flexion of right hip. Crepitation noted with palpation of active range of motion. Left hip with 5/5 muscle strength. Neurologic Alert and oriented x 3. Appropriate to the situation. Developmental: Endocrine: No issues Genitalia Penis midline, hair distribution even. Lymphatic: Lymph nodes nonpalpable Impressions: 12-lead ECG reveals normal sinus rhythm with occasional premature ventricular contractions; rate of 78 beats per minute. Chest x-ray without infiltrates or cardiomegaly. Bone x-ray reveals degeneration of right articular cartilage and overgrowth of bone in the right acetabulum and femoral head. Labs within normal limits. Plan: Surgical procedure of right total hip replacement has been discussed with Boyd Dubois, and the risks, benefits, and complications have been explained to him and his wife. Both agree to the surgical option. Opportunity for questions provided during discussion. Both Boyd and his wife verbalize desire to progress toward surgery. Patient scheduled for total right hip replacement today. Patient will be admitted to the orthopedic inpatient unit after surgery. Provider Signature: James McCray, MD Day Wednesday Time 05:30 PATIENT CARE BEGINS DEVELOPING NURSE THINKING BY IDENTIFYING CLINICAL RELEVANCE/SIGNIFICANCE OF VS. JO. LABS. ASSESSMENTS VS: Wed 10:35 Wed 11:00 T: Wed 11:15 Wed 11:30 Wed 12:30 Wed 13:00 P: 178 78 Wed 14:00 Wed 15:00 Wed 16:00 Wed 17:30 Wed 20:00 Wed 23:00 01:30 R: 06:45 BP: 197.2 97.4 97.4 97.6 97 98.2 98.491.2198.2 98 98.4196.2.99.4 94.8 Ro 86 86 82 82 84 82 84 86 84 oz 14 114 14 14 16 16 16 16 16 16. 1468 064/61410129784 126/20 (24/30 (1678 1248 tulos (104801624012844 1542,154/4 196% 96% 96% 96% 98% 98% 98% 98% 98% 98% 98% 96% 94% 93% 1618 14 11 O2 sat: 02 Deliver & Amount Provocative & Palliative Quality or Quantity Region or Radiation Severity Scale Timing Understanding 6 Thu 16:45 Chat VS data is RELEVANT that must be recognized as clinically significant? LAB/DIAGNOSTIC RESULTS: Current: High/Low/WNL Complete Blood Count (CBC): White Blood Cell [WBC] (4.5-11.0 mm 3) Hemoglobin [Hgb) (12-16 g/dL) Hematocrit [Hot] -Differ for males & females Platelets(150-450x 103/ul) Neutrophil % (42-72) 9000 39 360,000 Mor amar Low ) MC ک) What lab results are RELEVANT that must be recognized as clinically significant to the nurse? RELEVANT Lab(s): WHY is each lab Clinically Nursing Assessments/Interventions Required: Significant to your patient’s situation?