Care map on Psych pt?

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Ok, I am starting a new care map. I haven't seen the pt yet, but this is the info that I have: 51 y/o m presenting to ED with c/o weakness & being sick x 10d. He cannot keep his meds down, & has been attempting to crush them in order to take them, but has been throwing everything up. CT scan done d/t c/o 'left flank pain' showed right middle lung pneumonia, & a slightly distended gallbladder. His urine screen came back + for benzodiazepines, marijuana, & cocaine, but he denies drug use.

His past medical hx is significant only for bipolar disorder & chronic back pain d/t a 4 wheeler accident. He did threaten the dr in the ED w/bodily harm, but the dr stated that he didn't feel threatened & felt the pt was more of a manipulative antisocial personality. At home meds consist of albuterol, tessalon pearls, dolobid, lithium, Seroquel XR, tramadol, trazodone, flexeril, & naproxen.

My issue here is that my clinical instructor wants us to have the beginning of a care map ready when we come into clinicals. She expects us to (& has this entire semester) make our care maps based off of the patient's medical diagnosis. I understand that this is 100% incorrect, however I have to do it the way that she wants in order to pass this clinical.

Ok, what I have come up with so far is ineffective self-health management r/t presence of adverse personal habits (illicit drug use), & risk for [spread] of infection r/t inadequate secondary defenses.

Any ideas here? I have to come up with 2 more. :(

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I know that this is technically counter intuitive.....what she is doing is making you think about the patient's needs prior to class and as the nurse what are you looking for before you go in the room. All the potential "red flags" prior to entering the room. This is a bit out dated in accordance with NANDA purpose and focus.

So look at your information...... for you haven't had a chance to assess the patient

51 y/o m presenting to ED with c/o weakness & being sick x 10d. He cannot keep his meds down, & has been attempting to crush them in order to take them, but has been throwing everything up. CT scan done d/t c/o 'left flank pain' showed right middle lung pneumonia, & a slightly distended gallbladder. His urine screen came back + for benzodiazepines, marijuana, & cocaine, but he denies drug use.
So this patient has nausea and vomiting, lack of food intake and possible dehydration. He has "pain", pneumonia and possible Gall bladder disease who is weak and might be unsteady on their feet.

What problems can you think of this patient might have and what he might need?

SO ......this patient has a medical history of

bipolar disorder & chronic back pain d/t a 4 wheeler accident.
What risks does this patient have with these diseases since he isn't taking his meds.
albuterol, tessalon pearls, dolobid, lithium, Seroquel XR, tramadol, trazodone, flexeril, & naproxen.
What indications/side effects/toxticity might you consider with these meds.
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When I saw the patient all of his vitals were normal, lab values were normal....everything was normal, except he still had infiltrates in his lung. Doctor states that this is due to the fact that the cocaine he is using is 'cut' with 'bad stuff'. I am so lost!

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Specializes in PACU, pre/postoperative, ortho.

But everything is not normal. Make a problem list to start. (I love concept maps!)

-Pt c/o of n/v, weakness

-Both chronic & acute pain (left flank, back)

-Psychosocial issues/behaviors (history, verbal threats)

-Respiratory issues chronic vs acute (albuterol rx, pneumonia)

-illegal drug use

Reread Esme's post.

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