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Este Cmap, tiene informaciĆ³n relacionada con: Donkey Punch Pt, Patient Demographics Reason for Admission C/O Blurred Vision & Headaches, Patient Demographics Age 48yo, Interventions Assess ability to perform ROM, Patient Nursing Diagnosis, Patient Labs 11-15-12 Complete Blood Count All WNL, Interventions Assess ability to perform ROM, Patient Demographics Allergies Vestaril, Interventions Split or bivalve cast as needed to prevent skin breakdown and decreased tissue perfusion, Patient Medications Metoprolol (Lopressor) Beta Blocker 25mg PO BID Decrease BP, Monitor skin every shift for turgor, warmth, sensation, capillary refill, and for any impairments Rationale Healthy skin should have good skin turgor, be warm upon palpation, have full sensation present, and should be from from any other impairment, Patient Diagnostic Tests Angiogram @1200 We were not there at that time to know the results, Perform active &/or passive ROM Rationale Prevents joints from contractures & stiffness, maintains muscle strength, and prevents muscle wasting., Patient Demographics Religion Catholic, Assess coping strategies used by the pt in the past, cultural beliefs, and cultureal beliefs Rationale These may all play into how the patient and other loved ones will cope with their most recent loss, Assess ability to perform ROM Rationale Testing physical ability of the pt's joints will allow you to assess the abilities and limitations in order to guide therapy, Interventions Assess for symtoms of a fat embolism, Patient Admission Diagnosis Cerebral Aneurysm- a weakness in the wall of a cerebral artery causes a localized dilation usually found at the arterial junction of the Circle of Willis which can lead to subarachnoid hemorrhage. Pt was kicked in the head by a donkey 3-4 weeks ago. Has been having blurred vision, elevated BP, and increased frequency of headaches, Seek spiritual counseling if desired, for the pt & other family members Rationale Ones who has faith based beliefs appear to grieve faster and with closure than ones without spiritual based beliefs, Interventions Monitor nutritional status, Assess for symtoms of a fat embolism Rationale Sense of impending doom, pain in chest, S/S of shock, or rash on the chest are all indicators of a fat embolism