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Case Austin Community College - NURSING 341 vsim Vernon Watkins.CONCEPT MAP WORKSHEET
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Case Austin Community College - NURSING 341 vsim Vernon Watkins.CONCEPT MAP WORKSHEET
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CONCEPT MAP WORKSHEETDESCRIBE DISEASE PROCESS AFFECTING
PATIENT (INCLUDE PATHOPHYSIOLOGY OF
DISEASE PROCESS)
Pulmonary Embolism (PE) is the blockage of one or more pulmonary arteries by a thrombus, fat or air
embolus, or tumor tissue. These clots do not stop moving until they lodge at a narrowed part of the
circulatory system. A pulmonary embolus consists of material that gain access to the venous system and then
to the pulmonary circulation. The embolus travels with blood flow through smaller blood vessels until it
lodges and obstructs perfusion of the alveoli. The lower lobes of the lungs are most commonly affected and
approximately ten percent of patients die from a massive PE within the first hour. Anticoagulants significantly
reduces mortality.
Lewis, S. M., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical-surgical nursing:
Assessment and management of clinical problems. St. Louis, MO: Elsevier.
PATIENT ANTICIPATED
DIAGNOSTIC TESTS INFORMATION PHYSICAL
(REASON FOR TEST AND FINDINGS
RESULTS) Vernon Watkins is a • Shortness of breath
• 12-lead electrocardiogram (ECG) such as T-wave 69- year-old male who • Chest pain
inversion, ST-segment elevation, or the
development presented to the • Nausea
of an abnormal Q wave (may show changes
indicative of ischemia) Department 4 days ago with
+ • Vomiting
• Chest X-ray-may show infiltrates, atelectasis,
complaints of nausea, • Abdominal pain
elevation of the diaphragm on the affected side, or
a vomiting, and severe • Anxiety
pleural effusion abdominal pain and was
• Spiral CT-Scan with contrast
• Fever
• Arterial blood gas analysis-it may show admitted for emergent • Tachycardia
hypoxemia and hypocapnia (from tachypnea). surgery for bowel
• D-dimmer test
• Apprehension
• Prothrombin time perforation and underwent • Diaphoresis
• International normalized ratio a hemicolectomy. • Hemoptysis
• Syncope
ANTICIPATED NURSING INTERVENTIONS
• Maintain oxygen saturation greater than 92%
• If SpO2 less than 92% administer oxygen therapy to relieve hypoxemia and dyspnea and position client in
high- Fowler’s 90 degrees
• Initiate and maintain IV access.
• Administer prescribed medications
• Withhold medications that may cause respiratory depression
• Place 12 lead ECG to monitor cardiac status (dysrhythmias)
• Vital signs every 4 hours
• Monitor for signs of bleeding.
• Assess wound and IV site regularly.
Page 1 of 24
,• Chest X-Ray
• Spinal CT-scan with contrast
• Request need for arterial blood gas/stat labs
• Check to aPTT in six hours and then follow nurse driven IV heparin protocol
Page 2 of 24
, vSim ISBAR ACTIVITY WORKSHEET
INTRODUCTION Aurora Vera primary nurse at the medical surgical unit
Your name, position (RN),
unit you are working on
SITUATION Vernon Watkins is a 69-year-old male who presented to the Emergency
Department 4 days ago with complaints of nausea, vomiting, and severe
Patient’s name, age, specific reason abdominal pain and was admitted for emergent surgery for bowel perforation
for visit and underwent a hemicolectomy.
BACKGROUND Admitted on 07/22/2020 with a primary diagnosis of postoperative hemicolectomy. He is also getting treated
for a pulmonary embolism.
Current orders:
Patient’s primary diagnosis, date of -IV normal saline at 25 mL/hour
admission, current orders for -Oxygen to maintain SpO2 over 92%
-Continuous ECG and SpO2 monitoring
patient -Chest X-ray
-Spiral CT-scan
-12 Lead ECG - Cardiac monitoring
-D-dimer
-Check PTT Q6hrs and follow-up nurse driven IV
-Heparin protocol
-Arterial blood gas
-Venous blood
analysis Medications:
Morphine sulfate 4-6 mg IV push Q4hrs. PRN pain (withheld due to respiratory condition)
Heparin 80 units kg bolus
Heparin 18 units/kg/hr (25,000 units in 250 mL dextrose 5%)
ASSESSMENT I monitor the patient’s vital signs, oxygen level, and heart rhythm. Temp: 99,
RR: 24, Pulse: 112, BP: 156/94, Sp02: 91%, Pain: 3 (0/10). HOB High Fowler’s.
Current pertinent assessment data Heart sounds: rapid. Lungs: Clear bilaterally. Midline abdominal incision that is
using head to toe approach, clean, dry and intact. No redness, swelling or drainage. AOX3. Bowel sounds
pertinent diagnostics, vital signs present on all 4 quadrants. Last bowel movement was yesterday. Urinary
output was 400 mL at 0600. IV in right antecubital and is intact, no redness,
swelling or bleeding.
Heparin 80 units/kg bolus then 18 units/kg per hour IV patient has 1440 units/hr
in 250 ml dextrose 5% in water. Spinal CT detected a clot in segmental artery of
left and right upper lung. 12 Lead ECG shows sinus rhythm with signs of right
heart strain consistent with pulmonary hypertension. ABG: respiratory alkalosis.
Venous blood: Cl 101, HC03 21.1, aPTT 31, and PT 10. D-Dimer 0.9. The client is
allergic to
Penicillin.
RECOMMENDATION
• Continue to maintain adequate 02 levels
• Continue to maintain Pain levels
Any orders or recommendations • Continue to monitor vital signs and observing for signs of
respiratory distress
you may have for this patient
• Continue ECG monitoring
• Continued monitoring of aPTT and PT values and adjust
Heparin accordingly.
• Monitor for bleeding.
• Although patient would not be ambulating at this point. When clot
is resolved and doctor orders, ambulate patient from bed and
Page 3 of 24
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