University:
Keiser University
Course:
NUR 2032C | Care Management
Academic year:

2021
Views:

61

Pages:

2
Author:

do3ran7ut

Evaluation (Goals met/unmet)-15 pts Signs/Symptoms (Assessment)-10 pts Concept Map Template Medical Treatment/Collaborative Care (Planning)-5 pts Dietician- help patient understand a cardiac diet and how to manage at home. Counselor- help patient understand and cope with new onset diagnosis. Pt will be able to demonstrate active participation in necessary and desired activities and demonstrate increase in activity levels.(Met ) Pt will be acheive effective breathing pattern AEB normal RR, oxygen saturation with target range & Verbalize ease breathing (Met) MD- help patient maintain proper medication regimen for CHF. Run labs to make sure lab values remain stable. Frothy sputum Inadequate tissue perfusion Edema of lower extremities Medical History (Assessment)-5 pts DM Nurse- Help patient maintain and understand the proper methods to cope with breathing and eliminate SOB Goals/Nursing Interventions (Planning)-25 pts -Teach deep breathing exercises & relaxation techniques. -Provide adequate ventilation in the room. -Weigh the patient daily -Elevate head of bed -Commence fluid balance chart, monitoring the input and output ^ SOB Smoker(1/2 a day) Concept: Gas Exchange Covid X2 DX: CHF Obesity Nursing Diagnosis (Analysis)-30 pts Interrelated Concepts (Analysis)-5 pts Activity intolerance RT imbalance between oxygen supply and demand AEB SOB upon exertion Metabolism OSA Diagnostic Studies (labs, XR, etc.) (Assessment)-5 pts Ct scan(pending results) Mobility BNPNutrition Ineffective breathing pattern RT pulmonary congestion Chest xray secondary to CHF AEB SOB Perfusion Sleep ECG MRI