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Patient: RF von Mind Map: Patient: RF

1. Medical History and Meds

1.1. Lower GI Bleed

1.1.1. Bleeding in the esophagus, stomach, or duodenum and is characterized by frank, bright-red bleeding or dark, grainy digested blood (“coffee grounds”) that has been affected by stomach acids₅ Pantoprazole Proton Pump Inhibitor₁₃ Binds to an enzyme in the presence of acidic gastric pH, preventing the final transport of hydrogen ions into the gastric lumen₁₃

1.2. Alzheimer's Dementia

1.2.1. Degenerative, irreversible, progressive disorder of the cerebral cortex, especially the frontal lobe₆ Escitalopram SSRI₁₂ Selectively inhibits the reuptake of serotonin in the CNS₁₂

1.3. Parkinson's Disease

1.3.1. Neurologic disorder causing progressive deterioration due to dopaminergic neurons degenerating causing a loss of available dopamine₇ Levadopa-Carbidopa Antiparkinsonian Agents₁₀ Levodopa is converted to dopamine in the CNS, where it serves as a neurotransmitter. Carbidopa, a decarboxylase inhibitor, prevents peripheral destruction of levodopa.₁₀

1.4. Hypertension

1.4.1. Consistent elevation of systemic arterial blood pressure₈

1.5. Ischemic Stroke

1.5.1. Sudden impairment of blood circulation to the brain affecting neurologic function₉ Acetylsalicylic Acid Antiplatlet Agent₁₅ Inhibiting the production of prostaglandins – decreases fever/inflammation & decreases platelet combination₁₅

1.6. Multiple Mylemona

1.6.1. Type of blood cancer that begins in plasma cells, which proliferate interfering with the production of blood cells and causing soft-tissue masses or lytic lesions in the skeleton₁₀ Lenalidomide ImmImmunomodulatory and antineoplastic agents₁₆ Increases hemoglobin expression by erythroid cells, inhibiting proliferation of certain hematopoietic tumours cells, enhancing T cell, NK cell and NK T cell number and activity, and inhibiting angiogenesis by blocking the migration and adhesion of endothelial cells and the formation of micro vessels₁₆ Stem Cell Transplant Treatment when stem cells or bone marrow have been damaged or destroyed by disease or treatment for disease₁₇

1.7. Dysphagia

1.7.1. Difficulty swallowing

2. Admitting diagnosis: Enterocolitis with CDIFF

2.1. On Exam:

2.1.1. Abdomen discomfort Acetaminophen Inhibits synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS₁₁ Antipyretics, nonopioid analgesics₁₁

2.1.2. Abdomen firm and distended

2.1.3. Bilateral non-pitting edema

2.1.4. Fatigue Deconditioning Decreased mobility

2.1.5. Orientation Typically oriented to person but not place or time Less oriented as the day progresses

2.2. Inflammation of the colon and small intestine often resulting in response to an infection

2.2.1. Priority to address: physiological need₄

3. Lab Values

3.1. WBC:12.3

3.2. C-Reactive Protein: 120.2

4. Gastrointestinal System

4.1. No mobility aids used at home prior to admission

4.1.1. Wife states concern regarding his decreased mobility Lives at home in multilevel house with wife in Edmonton SDOH: Physical enviroment Fall risk with multiple levels of stairs Wife is a retired nurse - capable of providing a reasonable amount of assistance

4.2. Diarrhea

4.2.1. Encouraged increased intake of thickened oral fluids to maintain hydration and adhere to diet

4.2.2. Assisted to washroom regularly to prevent falls

4.2.3. Ensured patient's brief was changed regularly to increase patient comfort and decrease risk of skin breakdown Risk for Impaired Skin Integrity₁₈

4.3. Decreased appetite

4.3.1. Eating less than 25% of meals States he does not like the hospital food Pt states he will eat his wife's cooking upon returning home Nutrition, Imbalanced: Less than body requirements₁₈ Provided patient teaching on importance of nutrition while recovering from illness₃ Priority to address: food is physiological need₄

5. Mobility and Conditioning

5.1. 1PA with WA

5.1.1. Use of walker for ambulating Working with PT and OT Prevention of further loss of mobility

5.1.2. Barrier to discharge: Decreased mobility and inability to perform ADLS Worked with pt to perform ROM exercises Ambulated with pt in hallway and room Encouraged independence in ADLS

5.1.3. 2-4L o2 required to keep sats above 90% Activity intolerance related to impaired respiratory function₁₈ Barrier to discharge: o2 requirements Salbutamol Bronchodilator: Selective beta 2-adrenergic receptor agonist₁₉ Relaxes airway smooth muscle, increasing airflow₁₉

6. Legend

6.1. Family and/or Enviroment Involvement

6.2. Medication

6.3. Social Determinant of Health

6.4. NANDA Diagnosis

6.5. Barriers to discharge

6.6. Intervention

6.7. Abnormal assessment finding

6.8. Pathophysiology

7. Nursing

7.1. Promote patient health holistically₁

7.2. Focus on patient strengths and abilities₂

7.3. Provide support to patient in coping with changes₁

8. Patient Information

8.1. Male

8.2. 85Y

8.3. M1