Clinical expectations:
Discussion of the assigned clinical patient.
Concept Map which consists of:
1 nursing diagnosis
1 Goal
3 Nursing interventions with rationale
Evaluation
Completed medication cards
J.B. is a 58-year-old retired postal worker who has been on your floor for several days receiving plasmapheresis every other day for myasthenia gravis (MG). About a year ago, J.B. started experiencing difficulty chewing and swallowing, diplopia, and slurring of speech. Before this admission, he had been relatively stable. His medical history includes hypertension (HTN) and glaucoma. Recently, J.B. was diagnosed with a sinus infection and being treated. On admission, J.B. was unable to bear any weight or take fluids through a straw. There have been periods of exacerbation and remission since admission. His vital signs are Blood pressure 170/68 mmHg, Heart rate 108 beats/min, Respiratory rate 24 breaths/min, Temperature 101.8° F (38.8° C).
Current Medications: Pyridostigmine (Mestinnon) 60mg 3x dailyMetoprolol (Lopressor) 50mg dailyTimolol (Timoptic) 0.25% ophthalmic solution 1 drop to left eye dailyNew prescription Ciprofloxacin 250mg BID x 7 days.
Current Lab Values: WBC 12.6uL, RBC 5.2uL, Hgb 12.4g/dL, Hct 38.1% MCV 92fL, MCH 29pg, MCHC 34.6g/dL, Platelet Count 270uL, RDW 12.6%, Neutrophils 78%, Lymphocytes 14.0%, Monocytes 7.9%, Eosinophils 1.4%, basophils 0.1%, Immature Granulocytes 1.1%.
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