NUR 3130 Josephine Morrow week 15 vsim

CONCEPT MAP WORKSHEET DESCRIBE DISEASE PROCESS AFFECTING PATIENT (INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS) DIAGNOSTIC TESTS (REASON FOR TEST AND RESULTS) PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS ANTICIPATED NURSING INTERVENTIONS  Hand hygiene  Obtain vital signs  Assess venous ulcer and skin 2 hours  Inspect dressing and clean ulcer as specified in order  Measure ulcer size and depth  Provide developmentally and culturally appropriate education  Provide multidisciplinary approach to patient education  Instruct patient to keep legs elevated and wear sequential compression devices  Check providers orders and medication administration record (MAR) in the electronic health record (EHR)  Provide patient education on fall risk, improving venous return, and wound care  Make sure patient understands side effects of each medication when able to administer  Evaluate patient every 1 hour after administration of medication  Make a discharge plan for patient According to Porth’s (2019), chronic venous insufficiency is caused by many things such as, factors that increase venous pressure, incompetent valves in the veins or an obstruction, decreased function of the skeletal muscle pumps, inflammatory process and endothelial dysfunction. This causes the blood to flow in other directions. This can lead to tissue getting congested, edema which is inflammation due to the accumulation of blood, and eventual impairment of tissue nutrition. This can lead to an ulcer formation which is a shallow sore caused by the poor circulation. The most common site for these ulcers to form is in the lower legs, around the ankles. Electrolytes done to determine cell function  HC03-: 28 (High) Hepatic Function done to see if liver is working properly  Albumin: 3.4 (Low)  Prealbumin: 14.7 (Low)  Josephine Morrow  80 Y/O  White Female  DOB: 7/30/1940  Height: 160 cm  Weight: 90 kg  Allergies: Pen