History of Present Illness (HPI)
CONCEPT MAP
Concept Map
Student Name:
Instructor: Blackard
Patient Information (1)
Name: Josephine Morrow
Age: 80years
Gender: Female
Code Status: Full
DPOA: Unspecified but her daughter,
Sandra, is the next of kin
Living Will: Unspecified
Allergies: Penicillin
Chief Complaint
? A venous stasis ulcer.
? A possible stage II sacral pressure ulcer.
Admitting Diagnosis
? Her sacral coccyx has a venous stasis ulcer
? Urine incontinence
? Stage ii venous stasis ulcer on left lower
limb.
?
The HPI is Mrs. Morrow’s chief complaint of her venous stasis ulcer. She has been experiencing this for the past few
weeks and is getting worse.
? She has possible stage II pressure ulcers on her sacral coccyx. The patient is currently being treated with antibiotics,
pain medication, and a topical cream.
? The wound discharges a milky green liquid. Besides, the patient has brown hyperpigmentation on her lower legs with
edema.
? Vital signs were NSR, 134/72, HR: 78, RR 22, Temp 98.1F, oxygen saturation is 92% on 2 L nasal cannula, she c/o
pain on her lower legs with activity.
? Her VS are 101.1F, HR 138, RR 35, BP 83/56 Sats 88 on Simple face mask. Hypo active BS, her UOP has decreased to
20 ml/hr.
Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (3)
According to Millan et al. (2019), venous ulcers, also known as venous stasis ulcers, are a type of wound that occurs when blood
flow in the veins is slow or stagnant.
? Significant pain due to her condition, causing her to seek medical attention.
? Diabetes Type II
? Hypertension
Pathophysiology of Medical History (3)
?
?
?
?
Congestive heart failure: Several conditions, such as excessive blood pressure, coronary artery disease, and prior
heart attacks, can bring on the illness (Seah et al., 2019).
A history of pulmonary embolism. An obstruction of the pulmonary artery, known as a pulmonary embolism (PE), is
brought on by a substance that has moved through the circulation from another part of the body.
A history of hypertension (high blood pressure) means that her heart and blood vessels straining. Thus, this can lead
to heart problems, including a stroke. The patient is currently taking medications to control her hypertension and reduce
the risk of heart disease.
Deep Vein Thrombosis (DVT): A clot forms in a vein, usually in the leg. The clot can block blood flow and cause
pain, swelling, and a purple or black leg.
Surgical History
EricksonàDevelopmental Stage Related to pt.
& Cite References (1)
According to Erickson’s theory, the patient is in
the late adulthood stage of development. A focus
on generativity vs. stagnation characterizes the
stage. During this stage, individuals are typically
concerned with leaving a legacy and positively
impacting the world. Accordingly, this might be
why the patient is seeking help for a medical
condition. Orenstein and Lewis (2021) argued
that the late adulthood stage is linked to a higher
chance of acquiring cancer and other chronic
disorders. Therefore, it is important to provide
appropriate care to minimize her risk for these
conditions.
?
No history of any surgery
?
?
?
?
?
?
Social History
The patient has no history of alcohol and substance abuse.
She lives an inactive life and is alone.
She has poor nutritional behavior
She cannot provide self-care at home.
The patient consumes anything she comes across and does not follow her doctoràdiet guidelines.
She is a Christian, in particular, the catholic faith, she does not attend services.
Medical Management/ Orders/ Medications & Allergies (2)
Medication Name
Dose
RT
Freq.
MOA
Indications
Multivitamin
One tablet
PO
Once daily in
the morning at
0900
Insufficient vitamins
Upset Stomach
Diarrhea
Constipation
Review the patient’s labs to ensure that they
range.
Check for allergies
Zinc supplement
One tablet
PO
One tablet
daily at
0900hours
Treats cold to improve
the respiratory system
Nausea, Vomiting, and Diarrhea
Assess the patient’s serum zinc levels.
Aspirin
81 mg
PO
Daily in the
morning
It is a dietary
supplement that
contains a variety of
vitamins and minerals.
It is involved in the
metabolism of
carbohydrates, proteins,
and fats.
Aspirin works by
reducing the amount of
inflammation in the
body.
Reduce body
inflammation
Diarrhea, drowsiness, dizziness,
or ringing in the ears
Assess for allergies, check for current bleed
bruising.
Albuterol inhaler
360 mcg
INH
PRN
The medicine treat
bronchospasm in people
with asthma or other forms
of chronic obstructive
pulmonary disease
(COPD).
Treats bronchospasm
and bronchial asthma.
Dizziness, lightheadedness
nausea and vomiting
Monitor heart rate and blood pressure
Acetaminophen
650 mg
PO
After 6 hours
PRN for
wheezing
It blocks pain signals
sent from the brain to
the body
Relieve pain and
reduce fever
Nausea and vomiting
It is an anticoagulant
medication that
prevents the formation
of blood clots.
It is an antibiotic that
treat serious bacterial
infections.
Prevents blood clots
from forming or
getting larger.
Drowsiness or dizziness
Can cause bleeding problems,
including blood loss, bruising,
and nosebleeds.
Enoxaparin sodium
40mg
SQ
Subcutaneousl
y once daily
Vancomycin
750 mg
N/A
q12h
Metformin
500 mg
PO
twice daily
Hydrochlorothiazide
25 mg
PO
twice daily
Levophed
1-30
mcg/min
IV
Once daily
Bumex
0.5 mg IV
IV
Continuous
It reduces the amount of
glucose produced by the
liver and makes the
body’s cells more
sensitive to insulin.
It prevents the body
from absorbing too
much salt, which can
lead to fluid retention.
It relaxes the blood
vessels and increases
the amount of blood
that can flow through
them.
It increase the amount
of urine the body
produces to reduce the
amount of water the
It treat skin infections,
blood infections, bone
and joint infections,
and pneumonia.
Regulate blood
glucose and keep it
low.
Treat high blood
pressure and fluid
retention
To keep SBP >90.
It treat fluid retention
(edema) in people with
congestive heart
failure, liver disease,
Side Effects/Adverse
RN Considerations
Check the most recent creatinine level
Assess for signs and symptoms of DVT
Causes allergic reactions,
confusion
Review the patient ‘s medication history
Nausea and vomiting.
Dizziness.
Weight gain.
Blurred vision.
Fluid retention.
Drowsiness
Nausea
Dry mouth
Abdominal pain
Rash
Vomiting blood or black stools
Confusion
Assess low blood sugar levels and symptom
Abdominal pain
Dizziness
Lightheadedness or fainting
Assess the current blood pressure and heart
Assess the patient’s electrolyte levels
Assess the urine output and blood pressure.
Identify and explain abnormal findings related to Patientàdisease process
Test
Normal
Pt labs
WBC
4.40-11
18.2
Elevated because of the inflammation
Hgb
14.0- 16.0
7.2
Significantly low because of venous
stasis ulcer
Hct
Platelets
Na+
K+
Chloride
Co2
Creatinine
Blood
Glucose
36-42
150-450
135-145
3.5-5.0
95-110
23-29
0.6-1.3
76-106
20.1
415
140
5.0
105
19
1.8
298
BUN
Troponins
BNP
ALT
Ca+
Albumin
AST
Blood
cultures
Cholesterol
Triglycerides
HDL
LDL
Lactic Acid
Procalcitonin
CEA
CA 125
8.0-30.0
0.0-0.4
>125pg/mL
7 to 56
8.5 10.5
3.5 5.5
10- 40
40
Lower because of ulcer
Normal
Normal
Normal
Normal
Normal
Normal
Diabetes management
caused by immobility
Renal failure
8.8
3.1
Explanation of Abnormal
Medical Management and Collaborative Plan
Type2
?
?
?
?
?
?
Poor nutritional behaviors
Completing a focused assessment
Reviewing the labs
Performing a wound assessment and dressing change
Repositioning the patient to optimize venous return
Notifying the physician if the assessment warrants
Multivitamins, zinc supplements, aspirin, an albuterol inhaler, acetaminophen,
enoxaparin sodium, vancomycin, metformin, hydrochlorothiazide, and
levophed.
100 to 129
Vital Signs
40 – 59
100 -129
0.5 1
0-0.5

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