Megan Priddy

Concept Map # 4
Patient: D.E.E, age 64
Primary medical condition/diagnosis: Post colonoscopy complication from resection of a
tubulovillous adenoma in cecum
Pathograph of this condition:
- Risk factors include: diet high in red or processed meat, obesity, physical
inactivity, alcohol, long-term smoking, and low intake of fruits and
vegetables
- Adenocarcinoma is the most common type, which begins as a
adenomatous polyp, as it grows can enter into the muscularis mucosae and
can continue to spread to lymph nodes and vascular system
- Most common site of metastasis is the liver because venous blood
returning from the colon enters the liver via the hepatic portal vein
(Lewis, pg 985-986)
Medications for this condition (name, route, dose, action):
Normal saline: intravenous, 200 mL/hr, action: given to hydrate the patient so she
would not dehydrate due to the diarrhea
Secondary diagnosis #1: GI Bleed
Concise relationship between conditions: bleeding can occur from a colonoscopy if an
artery was accidently hit during the polypectomy (Lewis, pg 988)
Medications for this condition (name, route, dose, action):
PEG 3350-electrolytes (Colyte) (GoLytely): oral, 2,000 mL, action: PEG 2250, a
non-absorbable solution, acts as an osmotic. Sodium sulfate greatly reduces
sodium absorption. The electrolyte level causes virtually no net absorption or
secretion of ions
Morphine: IV, 2 mg, action: binds with opioid receptors in the CNS, altering
perception of and emotional response to pain
Secondary diagnosis #2: Hypotension
Concise relationship between conditions: when rapid amounts of blood are lost can lead
to hypotension especially when the volume is not being replaced in the patient. (Lewis,
pg 355)
Medications for this condition (name, route, dose, action)
Phenylephrine (Neosynephrine) 30,000 mcg in 0.9% NS: IV, 5- 50 mL/min
(titrated), action: causes local vasoconstriction of dilated arterioles, reducing
blood flow and nasal congestion
Contributing factors involved in this hospitalization such as lifestyle, PMH, FH, etc
Hypertension, A fib, COPD, non-insulin dependent diabetes mellitus, peripheral
neuropathy, bradycardia, hypokalemia, CAD, sick sinus syndrome, chronic
diastolic heart failure, S/P angioplasty with stent, pacemaker, anemia, sinoatrial
node dysfunction, mixed hyperlipidemia, CHF, and shortness of breath

Pertinent Physical Examination Findings:

Blood pressure would range from 100/64 to 121/55
HR stayed around 75 beats per minute
RR were 19 and were labored
Temperature was 97.4
O2 saturation was 98% on 2 L nasal cannula
Pain was an 8
Alert and Oriented x4
Abdomen was soft and tender
Heart sounds were audible for S1 and S2, no murmur heard, but monitor showed
normal sinus along with the use of her pacemaker
Lungs were coarse and diminished at the bases
Had a 20 G peripheral IV in left antecubital which was clean, dry, and intact
Had a 20 G peripheral IV in right forearm, which was clean, dry, and intact
Ambulated to the bedside commode, output was measured hourly and urine was
yellow/straw colored, clear appearance, no smell or sediment
NPO except for clear liquids until noon due to scheduled colonoscopy
MEWS score of 1, Braden score of 22, and Glasgow Coma Scale of 15, MAP
was 67 (goal was to keep it above 65)
Psychosocial/Spiritual issues and discharge needs:
Making sure that the patient is comfortable and not in any pain
Determining who was going to be at home to help care for her
Anticipated patient teaching required:
Discussed consent for the colonoscopy
Discussed dietary changes to help control her diabetes
Recent laboratory/diagnostic tests results with significance (i.e. why are they high/low?)
RBC decreased to 3.76, HGB decreased to 10.2 , Hct decreased to 31.3 these were
all low due to the large amount of blood that was lost overnight stemming from
her previous colonoscopy and polypectomy
Potassium decreased to 3.2 due to the chronic bloody diarrhea she had
experienced
Chloride increased to 10.9 could be due to her congestive heart failure or due to
her shortness of breath
Glucose increased to 121 could be high due to her diabetes or due to the stress on
her body from being in the hospital
Calcium decreased to 7.3 could be due to her diet or due to low protein levels

Priority Nursing Diagnosis (3 parts)

Deficient fluid volume related to lower GI bleeding (small or large intestine, rectum,
anus) caused by tumors as evidenced by melena, hypotension, weakness, thirst,
hematochezia (bright red blood per rectum).
Measurable outcome w/ timeframe:
By 1400, the patient will have a BP of at least 100/60.
Nursing interventions you used with rationales:
1) Monitor the color, amount, and consistency of hematemesis, melena, or rectal
bleeding; encourage the patient to describe un-witnessed blood loss accurately using
common household measures (e.g., a cupful, a spoonful, a pint).
Rationale: careful assessment of GI bleeding can help determine the exact site of the
bleeding.
2) Monitor the BP and HR for orthostatic changes (from the patient lying prone to highFowlers position).
Rationale: an increase in heart rate indicates hypovolemia. This change in rate is a
compensatory mechanism to maintain cardiac output. A drop in BP greater than 10 mm
Hg indicates that circulating blood volume is decreased by 20%. A drop in BP greater
than 20 to 30 mm Hg indicates that circulating blood volume is decreased by 40%.
3) Administer a vasopressin drip as ordered.
Rationale: vasopressin is a commercial preparation of antiduretic hormone that promotes
vasoconstriction and reduces bleeding. The drug may be given IV continuous drip,
piggyback bolus, or intra-arterially if a line was placed during an angiographic procedure
to a specific area (e.g., celiac artery for esophageal bleeding).
Evaluation:
The goal was MET. By 1400 the patients BP finally began to stay within the goal range.
(Gulanick, pg 617-618).

Reference
Gulanick, M., & Myers, J. L. (2014). Nursing Care Plans Diagnoses, Interventions, and
Outcomes (8th ed.). St. Louis, MO: Elsevier.
Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Harding, M. M. (2014).
Medical Surgical Nursing Assessment and Management of Clinical Problems
(Ninth ed.). St. Louis, MO: Elsevier.
Nursing 2015 Drug Handbook (35th ed.). (2015). Philadelphia, PA: Wolters Kluwer.

Guide for Reflection

Guide for Reflection Using Tanners (2006) Clinical Judgment Model
Program Thread: Safe, Quality, Evidence-based Practice
Today for clinical I got to have an interesting patient. She was not someone I
would have thought that would have been in the ICU. She was alert and oriented and did
not have a bunch of drains and tubes coming out of her. Since she had a rapid response
episode the night before, I got to see what happens afterwards. I really enjoyed working
with this patient. She was so appreciative of me just coming into her room and talking
with her. She even told me about how much she enjoys spending time with her
grandchildren.
I also really enjoyed working with my nurse today. I feel like I learned a lot and
got to really put the puzzle pieces together for my patient. I even got to witness my nurse
go over the consent form for the patients upcoming colonoscopy. Overall, I thought it
was a great learning day in the ICU.

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical
Judgment Model. Journal of Nursing Education, 46(11), p. 513-516.
List two goals for the next practicum experience:
1. Have a fun last experience in the ICU.
2. Continue to gain confidence in my nursing abilities.