Description
ML 82 years old female with h/o COPD, HIN, GERD, remote colon CA who presents with few days of worsening of shortness of breath . Patient is normally on 4l home O2 and has been Short of breath the past few days. Today inn the shower, she felt weak to the point where she couldn’t get up from the shower floor. Her husband called the EMS and Patient was noted to be sitting at 78.8 on RA.ROS: positive and negative ROS elements as per HPI. All others systems reviewed and negative.Physical exam:Pulse 124, BP 165/83, Resp 26, SPo2 98%, Temp 98.4 F(36.9 C)Please See the attachments for the care map rubric, a sample of care map and the remaining of the case study.
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A copy of the rubric must accompany the Care map when turned in.
NSG 240/315/430: Concept Map Evaluation Tool
(Attachment 8)
Name: _________________________ Date: ___________ Patient’s initials: ____________
Concept
Medical Diagnosis Includes pathophysiology, S&S,
diagnosis, and typical treatment
History and Physical assessment data from patient chart
and Patient Profile and Report sheet or any appropriate
tool. Include date of your assessment.
Lab test(s) and Diagnostic test(s): date obtained, normal
values, pt. results, Discuss rationale for order and reason
for abnormalities
List of Doctor’s orders (nursing worklist) including
rationale of why the orders were written for this patient.
Pharmacological interventions include the medication
name, dose, route, frequency, classification, 3 of the top
side effects and the rationale for taking
Analysis of the assessment findings (clustering of
subjective and objective data) evidenced by correctly
identifying the priority physiologic, psychosocial, and
educational diagnoses. Recognizes variant assessment
findings. Typed in paragraph form or list.
Comprehensive list of nursing diagnoses – prioritized.
Maximum
Points
3
5
5
5
10
10
2
Nursing Diagnosis # 1 Physiologic
To be included in concept map of Nsg 240/315/430
Nursing Diagnosis # 1 Physiologic (20 pts)
Correctly states selected nursing diagnosis (NANDA)
including related to/as evidence by
Goal is written using SMART format. Outcomes are
identified.
At least three (3) interventions. Interventions clearly
support the related goal.
One EBP rationale per intervention that clearly supports
the intervention including the citation for each
intervention.
Evaluation of interventions and whether objectives were
met or not met with a plan to revise care plan
Nursing Diagnosis #2 Psychosocial
To be included in concept map of Nsg 240/315/430
Nursing Diagnosis #2 Psychosocial (20 pts)
1.3.2018 df
3
6
4
4
3
Student
Points
Comments
Correctly states selected nursing diagnosis (NANDA)
including related to/as evidence by
Goal is written using SMART format. Outcomes are
identified.
At least three (3) interventions. Interventions clearly
support the related goal.
One EBP rationale per intervention that clearly supports
the intervention. Including the citation for each
intervention.
Evaluation of interventions and whether objectives were
met or not met with a plan to revise care plan
Nursing Diagnosis #3 Education
To be included in concept map of Nsg 315/430
Nursing Diagnosis #3 Education (20 pts)
3
Correctly states selected nursing diagnosis (NANDA)
including related to/as evidence by
Goal is written using SMART format. Outcomes are
identified.
At least three (3) interventions. Interventions clearly
support the related goal.
One EBP rationale per intervention that clearly supports
the intervention. Including the citation for each
intervention.
Evaluation of interventions and whether objectives were
met or not met with a plan to revise care plan
3
Uses at least 3 references (text, journal, and one other
scientific source) in APA format
Correct spelling and syntax.
3
Care Map format clearly shows relationships between
concepts.
All work is original or referenced appropriately in
APA format.
Total Points NSG 240:
10
Total Points NSG 315/430:
6
4
4
3
6
4
4
2
2
5
100
120
Satisfactory is 80%.
If satisfactory is not met, correct named deficiencies and resubmit for further evaluation on
____________ Initials____________
Faculty signature: ___________________________________
Student signature: ___________________________________
1.3.2018 df
Concept map
Nsg 240
Assessment
Subjective Data:
• Feelings of malaise
• Dizziness
• Fatigue
• Fever
• Pain level 9 out of 10
Objective data:
• Blood pressure, 99/72
• Temperature, 101.6° orally
• Pulse, 100 beats/min
• Respirations, 20 breaths/min
• Incision on the lower abdomen,
dry and clean.
• Patient able to void
• IncentiveSpirometer at the
bedside
• Moaning and leaning to one side.
Body Systems:
Respiratory
• Respiration 20 breaths/min
• Incentive Spirometer at the
bedside
Cardiovascular
• Blood pressure, 99/72
• Pulse, 100 beats/min
Integument
• Temperature 101.6 orally
• Incision on the lower abdomen,
dry and clean
Neuro/Sensory/Mental Status:
• Feelings of malaise
• Dizziness
• Fatigue
• Fever
• Pain level 9 out of 10
DIAGNOSIS
•
PSEUDOCYST OF
PANCREAS
•
PANCREATIC CYST
MEDICATIONS
•
•
•
•
Gordon Pattern and
cluster data
Elimination
ACETAMINOPHEN
•
•
HEPARIN
HYDROMORPHINE
Patient able to void
Temperature, 101.6 F
LACTATED RINGERS
Gordon Pattern
and cluster data
Activity-Exercise
•
•
•
•
•
•
Gordon Pattern and
cluster data
Cognitive /Perceptual
Respirations, 20
breaths/min
Blood pressure, 99/72
pulse, 100 beats/min
Incision on the lower
abdomen
Moaning and leaning to
one side
Incision on the lower
abdomen, dry and clean
• Feelings of malaise.
• Dizziness
• Fatigue
• Fever
• Pain level 9 out of 10.
Evidence-based rationale for interventions
Preventing the pain is one thing that a patient
experiencing it can consider. Early intervention may
decrease the total amount of analgesic required.
Patient:
Right dosage of opioids must be administered to the
client at the right time and right dosage in order to
prevent any chance of chronic postsurgical pain. If the
full dosage of opioids are not taken, it can lead to
chronic pain which may cause the patient to depend on
opioids. In addition to these, side effects must be
discussed with the client.
Situation
:
24 – year old female
admitted to the hospital
for treatment of a
Pancreatic cyst.
Client should be encourage to ambulate with
assistive devices. This is because ambulation with
assistive devices reduce the risk of falling which will
help the patient to recover on time. It also will help to
promote blood flow of oxygen throughout the body
while maintain normal breathing functions.
Vital signs are important component of patient care.
This will help to determine the treatment and provide
critical information needed to make life-saving
decisions, such as heart rate, blood pressure, pain level
changes all contribute to fall.
Providing hot or cold compress also help to decrease
pain. Cold treatment reduces inflammation by
decreasing blood flow. Heat treatment promotes blood
flow and helps muscles relax.
Providing fall wrist band to help providers to identify
fall risk patients which will help to monitored. This will
help prevent fall and as well as injuries to patients
during their hospital stay.
References
Capriotti, T., Frizzell, J. P., Pathophysiology. Introduction
Concepts and Clinical Perceptive. Retrieved from
https//fadavisreader.vitalsource.com
Medical News Today (2014-2019). Heat and cold
treatment . Retrieved from
https//:www.medicalnewstoday.com/articles
Nursing
240
Priority Nsg Dx:
Acute pain Related to diagnostic procedure, Evidence by
pain level 9 out of 10, moaning and leaning to the side,
incision of the lower abdomen, clean and dry, temperature
101.6 F.
2rd Nsg Dx:
Risk for falls Related to opiates, Evidence, dizziness, fatigue,
BP 99/72, Feelings of malaise, moaning and leaning to the
side.
Intervention
Goal/Expected outcomes:
•
Foreseeing the need for pain relief by
providing the total amount of analgesic
required for the client.
•
Patient will describe satisfactory pain control at a level
less than 3 to 4 on a rating scale of 0 to 10.
•
Administer opioids and monitor effects of
opioids such PCA, hydro morphine,
acetaminophen to client as ordered by
physicians and encourage the use of
incentive spirometer.
Providing hot or cold compress to help
decrease the pain.
Encourage client to safely ambulate by
calling for help and using of assistive
devices.
•
Patient will ambulate without sustaining fall during her
hospital stay.
•
•
•
Monitor client’s vital signs as well as
evaluating pain levels.
•
Providing signs or secure wristbands as
identification to remind healthcare
providers to implement fall precautions
behaviors.
Evaluation:
•
Patient stated that “My pain level is 2 on a rating scale of
0 to 10.
•
Patient able to ambulate 2 laps without any fall.
References
Capriotti, T., Frizzell, J. P., Pathophysiology. Introduction Concepts and Clinical Perceptive. Retrieved
from https//fadavisreader.vitalsource.com
Doenges, M. E., & Moorhouse, M. F. (2013). Application of nursing process and nursing diagnosis: an
interactive text for diagnostic reasoning (6th ed.). Philadelphia: F.A. Davis.
References
Capriotti, T., Frizzell, J. P., Pathophysiology. Introduction Concepts and Clinical Perceptive. Retrieved
from https//fadavisreader.vitalsource.com
Medical News Today (2014-2019). Heat and cold treatment . Retrieved from
https//:www.medicalnewstoday.com/articles
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