University:
Herzing University
Course:
NSG 121 | Health Assessment
Academic year:

2023
Views:

403

Pages:

1
Author:

Bailee C

Nursing Process Concept Map # 1 Concept: Perfusion Medical Diagnosis: CHF Exacerbation Assessment Data (clustered data): Assessment Data 2+ Edema BLE, Fatigue, Sensitive to cold Assessment Data: Nursing Diagnosis (actual, risk or health promotion): Ineffective Tissue Perfusion related to decreased cardiac output aeb 2+ edema and sensitivity to cold ST Goal: Pt exhibits growing tolerance to activity aeb walking to the nurse’s station and back twice daily. LT Goal: Pt will show signs of adequate cardiac output aeb no edema noted on lower extremities bilaterally by discharge Nursing Interventions: Place on fall precautions Massage area affected by edema SCDs Elimination on areas affected by edema #Utilize 3 Concept: Educate on 4 energy-saving techniques to help decrease Assessment Data (clustered data): fatigue Constipation, loss of appetite Nursing Diagnosis (actual, risk or health promotion): Constipation related to loss of appetite aeb inadequate food intake ST Goal: Pt identifies 3 measures that prevent and treat constipation by end of shift # 4 Concept: Depression Patient is a 78 y/o widowed female who is A&O x3 and presents with Congestive Heart Failure. VS: B/P 110/60, Respirations 20, Heart rate 56, Height 5’4 and Weight 115lbs. Patient states she is fatigued with poor memory and concentration, sensitive to cold, and loss of appetite not eating much over the last week with constipation. Previous smoker 20 years ago. Pt’s daughter states weight loss of 22 lbs. in 6 months. Physical assessment shows dull hair, pallor, anorexia, 2+ edema in BLE, heart sounds are distant, and lung sounds clear but diminished. Another Nursing diagnosis that could be chosen is a risk nursing diagnosis: Risk for falls due to age and history of falls. Loss of appetite, pt states feeling of helplessness, anorexia, constipation, fatigued and poor memory and concentration Nursing Diagnosis (actual, risk or health promotion): Helplessness related to hospitalization aeb pt states “she feels even more helpless now” ST Goal: Pt will get out of bed and walk to nurse’s station by 10am daily. LT Goal: The pt will demonstrate initiative, self-direction, and autonomy in decision making by discharge. Nursing Interventions: # 2 Concept: Nutrition Provide openings for pt to verbalize feelings of hopelessness Assessment Data (clustered data): Encourage the pt to recognize his/her own strengths/ability Loss of 22lbs over 6 months, Pt reports loss of appetite, is unable to achieve and respect pt’s Nursing Diagnosis (actual, risk or health promotion) Imbalanced Nutrition: Less than body requirements related to loss of appetite AEB loss of 22lbs over 6 months. ST Goal: Pt eats 20% of daily meals LT Goal: Patient maintains passage of soft, formed stool at a frequency perceived as “normal” by the patient by discharge. LT Goal: Pt gains 1-2lbs and exhibit fewer signs of Nursing Interventions: Nursing Interventions: Encourage increased fluid intake if not contraindicated medically Confirm pt food preferences and coordinate meals with dietician Educate pt on high fiber food options Encourage a regular period for elimination malnutrition by discharge Give the explanations to the patient about the benefits of adequate nutrition as well as negative consequences of nursing diagnosis for malnutrition Ensure proper positioning while eating