Running Head: NURSING CONCEPT MAP #1 1

Concept Map #1

Pedro Louzan

West Coast University

Professor Stepanyan

September 5, 2020
 Concept Map
Student Name: Pedro Louzan
Instructor: Professor Stepanyan Erickson’s Developmental Stage Related to pt. & Cite History of Present Illness (HPI), Pathophysiology of Admitting Dx
2 References (1) (Cite References) Medical, Surgical, Social History (1).
The patient was a 46 y/o male in stage 7 of Erickson’s
NURSING CONCEPT MAP #1 developmental age. This is the adulthood stage of Generativity
Patient Education (In Pt.) & Discharge Planning (home needs) Vs. Stagnation. Mr. Richardson is in the Generativity spectrum See attached.
of this stage as he is proud of his job, is fulfilled by his family
See attached. and volunteer work at the local soup kitchen. He feels that he Medical History
contributes positively to his community and has a strong sense
of self. (Orenstein, 2020)
See attached.

Surgical History

See attached.

Cultural considerations, ethnicity, occupation, religion, Social History

family support, insurance. (1) (14)
Socioeconomic/Cultural/Spiritual Orientation & See attached.
Psychosocial Considerations/Concerns, to include
the following Social Determinants of Health
Patient is economically stable, self-employed IT specialist,
owns his own house and has a HMO insurance. Patient is
Caucasian, Married with 2 children twin boys in high school.
Patient is non-denominational Christian and attends services
every week. Patient has a strong support system through
Diagnostic Test/ Lab Results with dates family, friends and religious community. (Healthy People,2020)
and Normal Ranges (3)

Test Norms Date Current

Value Patient Information Chief Complaint
(1)
Name: T.R. Pain with urination
Age: 46 Admitting Diagnosis
Gender: M
Code Status: Full Code Urolithiasis
DPOA: No
Living Will: No

Medical Management/ Orders/ Medications & Allergies (2)

Name Dose RT Freq. MOA RN Onset/Peak

See attached. Considerations /Duration
(Insulin)

See attached.
 Priority nursing diagnosis #1
3 Color: Pale
Impaired urinary elimination
related toNURSING CONCEPT MAP
stimulation of the
bladder by calculi, renal or
ureteral irritation as evidenced
by oliguria.
Outcome/Goal #1
Patient will void in normal
amounts and usual pattern by
end of shift.
Interventions #1
1). Promote sufficient intake of fluids
2). Offer cranberry juice if possible
3). Determine normal void pattern and
note variation.
4). Encourage walking with assistance.
Potential Complications/ at
risk for
Patient at risk for
deficient fluid
volume related to
nausea/vomiting
Vital Signs (4) Neurological (5) Cardiovascular (6) Respiratory (7) Priority nursing diagnosis #2
Breath sounds clear
Temp: 98.4 oral Alert and oriented times Skin: warm, diaphoretic bilateral. 28 breaths Deficient knowledge related to
#1
Pulse: 112/radial 4. GCS 15. Edema: None /min, good tidal unfamiliarity with information
Respiratory Rate: 28, Motor function intact. Cap Refill: <3 secs volume. resources as evidenced by
good effort and tidal Pulses to extremities +3. Telemetry: Sinus statement of misconception.
volume. Sensation intact. tachycardia Patient states “I drink 2 table
BP: 178/105 Pupils PERRLA. spoons of olive oil every day I
SpO2: 94% RA shouldn’t get these anymore.”
Nutrition/Hydration GI (9) GU (10) Rest/ Exercise (11)
(8) Bowel sounds: Normal Urine: yellow/red On bed rest,
Diet: Standard Western Last bowel movement: (+) pain on voiding Range of motion: active
Diet. 1500 day previous Last void 30 cc Mobility Aids: None
(+) Nausea, Color: Brown Gate: un-steady due to
(+) Vomiting No incontinence pain management
Mucus membranes: Abdomen: Non-tender, Functional Level:
independent Outcome/Goal #2
moist unremarkable. Patient will explain proper
Skin Turgor: normal understanding of life style
changes and information to
Integumentary (12) Endocrine (13) Psychosocial (14) Misc. (Ht/Wt) reduce the formation of stones
Skin intact. Pale and (-) for thyroid disease. Cooperative. 188 cm understand future recurrences as
diaphoretic skin noted. (-) for Diabetes Understands direction. 81.5 kg explained by staff.
Mellitus. No difficulty making
decisions. Judgment not
impaired. No
psychological History. Interventions # 2
1). Consult dietician to help patient
with diet modification.
2) Provide literature to patient on
Assessment/ Evaluation #1 Assessment/ Evaluation #2 urolithiasis and review answering
1). Goal met. Patient increased fluid intake to 16 cups 1). Goal met. Dietician met with patient and developed meal questions patient and wife may have.
2). Goal met. Patient tolerated cranberry juice modifications that the patient can follow. 3). Promote activity, explain that
3). Goal met. Discussed and evaluated patients previous void 2). Goal met. Patient given several pamphlets on urolithiasis inactive life style contributes to stone
pattern and compared to current state. and went through each with RN asking questions through out to formation.
4). Goal met. Patient was able to ambulate with the assistance ensure understanding. 4). Identify signs and symptoms
of CAN and wife. 3). Goal met. Patient states he will begin attending yoga with requiring medical evaluation to
(Henry et al. 2016) his wife and start bike riding again if approved by his doctor. prevent complications in case of future
4). Goal met. Patient was able to repeat back all signs and occurrence.
symptoms that should indicate immediate medical intervention.
PC Outcomes/Goal PC Interventions PC Evaluation Plan
1). Monitor patients I/O. 1). Goal met. Pt I/O with normal limits indicating maintenance of
Patient will drink 16 cups of fluids 2). Offer patient beverages he likes fluid balance.
by end of shift. 3). Consult primary physician for an order for Zofran. 2). Goal Met. Pt was given cranberry juice along with water to
4). Monitor vitals for indication of fluid imbalance supplement fluid intake. Cranberry juice helps to acidify the
urine and break up crystals.
3). Goal met. Patients primary placed order for Zofran, an anti-
emetic medication to help relieve vomiting.
4). Goal met. Pt vitals remained within normal limits
(Lewis, S., Bucher, L., Heitkemper, M. and Harding, M. 2017)
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NURSING CONCEPT MAP #1
History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References)

Medical, Surgical, Social History (1).

History of Present Illness

Upon EMS arrival, a 46-year-old male was found in the pacing in living room.

Per EMS on scene, the wife reported that the patient had been having back and flank pain

for several hours and fire had taken a set of vitals and checked the patient’s blood sugar.

Wife is a good historian stating that patient only has a history of kidney stones x3 in the

past 5 years. Wife states that the patient takes no medications at home and has an allergy

to sulfa drugs. EMS transported patient to ED, en route, an IV of D5 1/2NS was

established and 4mg of morphine sulfate were administered.

Upon assessment of the patient, the patient appeared pale and slightly diaphoretic.

Patient was warm to touch and laying fetal position on hospital bed. Patient appeared to

be in severe pain, responds to verbal stimulation with intermittent moaning. Patient was

alert and oriented to person, place, time and situation (A/O times 4) and requested pain

management. Patient’s pupils were PERRLA. Patient has good range of motion, is able

to follow commands and has equal grips and symmetry. Patient’s blood glucose was 68.

Focused Assessment

Focused assessment reveals patient has significant flank pain stating it is a 10/10

on pain scale, dull and sharp, radiating to the groin. Patient states pain is constant with

waves of increase. Pt states he feels the need to urinate all the time but is only able to

produce small amounts of urine. According to patient he noticed blood in his urine the

last 4 times he tried to urinate. Physical inspection of the patients back, flank and groin
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NURSING CONCEPT MAP #1
are unremarkable, there is increase in pain on palpation and percussion. Palpation shows

slight distension of the right kidney.

Patient interventions

Patient was initially placed on a D5 1/2NS and given 4mg of morphine sulfate by

EMS personnel. EMS personnel took vitals and a blood sugar check was performed.

After a rapid assessment, the patient was placed on the EKG showing sinus tachycardia.

Patient was placed in the ambulance via stretcher.

On patient reassessment, the patient appeared pale and diaphoretic. The patient

was able to follow commands and able to answer questions appropriately. Patient was

alert to person, place, time stated that he had been having pain for the last few hours. Per

the patient, he had a history of kidney stones with 3 occurrences in the last 5 years.

Patient has no known allergies and takes no medication at home. Patient had a decrease

in urinary output over the last day or so with pain starting 6-8 hours ago. Patient said he

thought the pain would go away but only intensified. Patient was placed in hospital gown

after having vomited on his clothing. Patient was negative for chest pain, dizziness,

shortness of breath and positive for nausea and vomiting. Vital signs were assessed every

30 minutes

Pathophysiology of Admitting Diagnosis

Patient is admitted for urolithiasis (kidney stones) a common development in the ureters

where deposits can form crystalline structure ranging from a grain of sand to a pebble or

larger. The deposits are most commonly calcium oxalate and calcium phosphate. Other

forms include uric acid, struvite and cystine. The crystalline structures have jagged edges

and can damage the ureter causing bleeding and pain as it attempts to pass. Depending on
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NURSING CONCEPT MAP #1
the size of the formation it can pass freely or get stuck and obstruct the path of urine. An

obstruction of the ureter can cause swelling of the kidney and lead to acute renal injury.

Calculi can be single or multiple.

(Lewis, S., Bucher, L., Heitkemper, M. and Harding, M., 2017).

Medical History

The patient has a past medical history of previous urolithiasis related to poor diet

and chronic dehydration. Poor diet and dehydration increase the formation of calculi.

Dehydration causes urine to concentrate increasing the production of uric calculi, while

high-purine foods such as red meat, organ meats, beer/alcoholic beverages, meat-based

gravies, sardines, anchovies and shellfish increase urine acidity increasing the formation

of calculi as well.

Surgical History

Patient denied surgical history.

Social History

Patient drank alcohol daily and diet consist of predominantly red meat and

potatoes. Patient states he doe not drink much water, but does drink 1 liter of cola per

day. Patient denies any use of illegal drugs and denies any smoking history.

Medical Management/ Orders/ Medications & Allergies (2)

NKDA

Name Dose RT Freq. MOA RN Considerations Onset/Peak/Duration

(Insulin)

D5 in 0.45% 150ml/ IV Conti Hypotonic Document baseline O: Rapid

NS hr nuous electrolyte vitals, monitor for P: unknown
infusi solution fluid volume deficit, D: end of infusion
on risk for increased ICP,
avoid excessive
infusion.
Morphine 4mg IV PRN Binds to opiate Obtain baseline O:rapid
Sulfate max receptor sites to respiratory rate and P:20min
of 20 decrease pain monitor for possible D:7hr
mg respiratory depression.
Zofran 4mg IV once Serotonin Monitor for electrolyte O:30min
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NURSING CONCEPT MAP #1
receptor imbalance and P:1-1.5hr
antagonist tachycardia in rare D:24hr
cases

(Vallerand and Sanoski., 2013).

Diagnostic Test/ Lab Results with dates and Normal Ranges (3)
Renal CT (with contrast) Calculi noted in R ureter

24 hr Urinalysis Pending

Test Norms Date Current Value

RBC 4 – 4.5 09/05 4.7

WBC 5 – 10 09/05 6.5
Hgb 14 – 17.4 09/05 16.9
Hct 42 – 52% 09/05 49
Platelets 140 – 400 09/05 380
MCV 82 – 92 09/05 82
BUN 10 – 20 09/05 24
Creatinine 0.6 – 1.2 09/05 1.6
AST 0 – 35 09/05 22
ALT 4 – 36 09/05 31
INR 0.9 – 1.2 09/05 1.1
PT 11 – 14 09/05 11.6
aPTT 16 – 40 09/05 20
D-Dimer 0.43 – 2.33 09/05 1.8
CRP <3 09/05 1.2
Lactic Acid 6.3 – 22.5 09/05 10
Blood Cultures N/A 09/05 Pending

Test Norms Date Current Value

Albumin 3.5 – 5.2 08/15 3.6

ALP 30 – 120 08/15 46
Na+ 135 – 145 08/15 139
Ca+ 9 – 10 08/15 9.8
K+ 3.5 – 5 08/15 4.1
Glu 80 – 110 08/15 72
Bicarb 21 – 28 08/15 23
Cl+ 98 – 106 08/15 102

Test Norms Date Current Value

pH 7.35 – 7.45 08/15 7.29

PaCO2 35 – 45 08/15 40
PaO2 80 – 100 08/15 96

(Fischbach and Fischbach., 2018)

Vital Signs
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Time 1805 1900 1930
Temperature 98.4 98.5 98.7
Pulse 110 Sinus 100 Sinus 102 Sinus
Tachycardia Tachycardia Tachycardia
Respiratory rate 24/rapid 20/normal 20/normal
Blood Pressure 178/105 150/928 146/89
SpO2 86% on room air 95% CPAP 98% high flow O2
Neurological GCS = 15 GCS = 15 GCS = 15
Eyes=4, verbal = 5, Eyes = 3, verbal = Eyes = 4, verbal =
motor = 6. 5, motor = 6. 5, motor = 6.
Pain 10/10 7/10 5/10

Patient Education (In Pt.) & Discharge Planning (home needs)

Patient required education in managing his diet and when to call a doctor for signs

of recurrence with possible complications. Patient and family will be instructed to

monitor for signs cramping and changes in urinary pattern, vomiting as a result of pain

that is not relived with medication. Patient was instructed to call his physician if he

develops any signs or symptoms that may indicate recurrence. Patient will be instructed

to call physician prior to taking any over the counter medications including supplements

and natural herbal extracts. Patient will be instructed to call 911 for debilitating pain and

recurrent vomiting. The patient will be educated on proper diet and adequate hydration.

Patient should add an exercise routine to current lifestyle to promote activity and

decrease likelihood of recurrence. The patient should schedule follow up with dietician

to monitor progress and make adjustments as need to diet.

The patient will receive education on over the counter medications and

supplements that can be helpful in mitigating recurrence as well as which supplements to

stay away from. Patient has been instructed to strain urine at home to help in detection of

possible future calculi development. Patient is to follow up with primary care physician

in 2 weeks to check progress and for follow up laboratory testing.

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References

Carpenito, L. (2017). Nursing diagnosis: application to clinical practice. Wolters Kluwer

publishing.

Determinants of Health. (n.d.). Retrieved September 06, 2020, from

https://www.healthypeople.gov/2020/about/foundation-health-

measures/Determinants-of-Health

Fischbach, F and Fischbach, M. (2018). A manual of laboratory and diagnostic tests. 10th

edition. Wolters Kluwer Publishing.

L;, O. (n.d.). Eriksons Stages of Psychosocial Development. Retrieved September 06,

2020, from https://pubmed.ncbi.nlm.nih.gov/32310556/

Leslie, S. (2020, July 10). 24-Hour Urine Testing for Nephrolithiasis Interpretation.

Retrieved September 06, 2020, from

https://www.ncbi.nlm.nih.gov/books/NBK482448/

Lewis, S., Bucher, L., Heitkemper, M. and Harding, M. (2017). Medical-surgical nursing.

10th edition. Elsevier publishing.

Semins, M., & Matlaga, B. (2010, February). Medical evaluation and management of

urolithiasis. Retrieved September 06, 2020, from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3126068/

Vallerand and Sanoski (2013). Davis’s Drug Guide for nurses. 13th ed. F.A. Davis.