Nursing Concept Map Lab

Concept Map (TEMPLATE) Patient Information (1) Patient Initials: M.D. Age & Gender:91/ Female Height/Weight: 57kg/4’11’’ Code Status: DNR Living Will/ DPOA: Yes, Niece History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1). WHAT BROUGHT THE PT TO THE HOSPITAL? WHAT EVENTS LEAD UP TO THIS? WHAT HAPPENED WHEN THEY GOT TO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE? 91 years old hispanic female admitted from Baptist Acute Rehabilitation Hospital following treatment for left shoulder, left femur for which she had surgery on left shoulder and left hip femur. Extracapsular fractures of the proximal femur that occur between the greater and lesser trochanters are known as intertrochanteric fractures. These fractures can affect both young and old people, but they are more common among the elderly. The lower extremities of these patients are usually short and externally rotated. It is critical to assess the skin where the fracture is (to determine if open or closed) as well as the neurovascular condition. The treatment of these fractures is deemed urgent rather than emergent (Attum, 2021). Medical History: (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED MEDICAL PROBLEMS Hypertension, Dementia, Heart Failure, Acute encephalopathy, Aspiration Pneumonia, Chronic Rhinitis, GERD, Anemia, Vitamin Deficiency, Hyperlipidemia, Iron Deficiency, Insomnia, UTI, Constipation. *** Allergy to Penicillin Surgical History: (SEE RUBRIC REQUIREMENTS) PAST DIAGNOSED SURGICAL PROBLEMS Arthoplasty, Open reduction and internal fixation of the left fracture, cholecystectomy, Hysterectomy. Chief Complaint Fracture and hospice care Admitting Diagnosis & Admission Date Social History: SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE Never smoked Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns: include the following Social Determinants of Health (SDOH) Hispanic, Spanish speaker, never married, catholic, niece as only family and advance directive, medicare. Erickson’s Developmental Stage Related to pt. & Cite References (1) Ego Integrity vs. Despair - Late Adulthood (65 years old and older) **Patient will reflect and accept their life. At this stage, the most essential event is coming to terms with one's entire life and reflecting positively on it. Developing a feeling of integrity, according to Erikson, entails fully accepting oneself and coming to grips with mortality. Accepting responsibility for your life and being able to repair your mistakes in order to achieve self-satisfaction is critical. The failure to do so leads to a sense of hopelessness (Cramer, Flynn, & LaFave, 1997). Concept Map (TEMPLATE) Medical Management and Collaborative Plan (from MD, PT, OT notes….etc.) *Consider past 24 – 48 hours Key Diagnostic Tests/ Procedures and Lab Results with Dates and Normal Ranges (3) Lab Test Normal Ranges Admission Lab Values Current Lab Values Normal/Abnormal WBC 3.8-10.8 k/uL 7.5 7.5 Normal RBC 3.9-5.3 M/uL 4.71 4.71 Normal HMG 12-15.6 g/ dL 12.7 12.7 Normal HCT 35-46% 39.4 39.4 Normal The plan for the patient is to follow and continue the medication regiment and comfort measurement as needed, in addition to hospice care. Prognosis: Stable Patient Education (In Pt.) for Transfer/ Discharge Planning ASSESS LEARNING STYLE: Auditory and Visual LEARNING PREFERENCE: WRITTEN, VIDEO, etc. Patient is not alert to place, time, event only to herself. She can follow commands however due to dementia a lot of teaching are lost due to the lack of learning ability, due to cognitive impairment. LEARNING BARRIER(S): LANGUAGE, EDUCATION LEVEL ASSISTIVE DEVICES: GLASSES, HEARING AIDES, etc. Patient speaks Spanish, has Dementia, and uses glasses. ANTICIPATED TRANSFER/ DISCHARGE PLANNING: PRIORITY GOALS TO BE ACHIEVED to TRANSFER or DISCHARGE -Hospice Care EQUIPMENT - Wheelchair, Walker TREATMENT- Hospice Care, nursing intervention for comfort REFERRALS NEEDED- Not needed, hospice care Medications & Allergies (2) Medication Name Dose Aspirin 81mg Ipratropium Donepezil Atorvastatin 1 puff 10mg 10mg Route Freq. Indications Oral daily HPN Mechanism of Action Side Effects Nursing Considerations Anticoagulant GI distress Long term use can cause Anti-inflammatory Headache PUD Oral T.I.D Cough Bronchodilator Tachycardia, anxiety etc Rinse mouth after use Oral daily Dementia Cognitive-enhancing N/V/D, weight loss Increase stomach acid Oral Bedtime Hyperlipidemia Antihyperlipidemia nosebleed, N/D Liver Function Test Concept Map (TEMPLATE) Vital Signs (4) BP: 169/98 TEMP: 97.6 HR: 67 O2 Sat: 96% RR: 17 PAIN: 0 (Scale from 0-10) Musculoskeletal (8) Right ankle posterior tibial pulse +2 Left ankle posterior tibial pulse +1 Strength +3 in all extremities Limited active ROM in all extremities Walker as assisted aid Integumentary (12) Braden scale 14 skin turgor elastic no cyanosis nor jauntice no pressure injuries color uniform normal to ethnicity scar on left shoulder, left hip, and RUQ of the abdomen. ASSESSMENT/ REVIEW OF SYTEMS Neurological (5) Alert & Oriented x1 (person) Can follow simple commands PEERLA Generalized Weakness Speech Clear Romberg test negative, need assistive device to ambulate. GI Hydration/Nutrition (9) Soft, round and nontender abd. no masses palpable. RUQ vertical scar. Bowel sound present in all 4 quadrant. Last bowel movement documented in the morning (today). Endocrine (13) Cardiovascular (6) Rate and rhythm regular S1 and S2 present, no JVD, No Carotid bruit heard, no edema present, warm to touch, capillary refill >3 sec, no murmur heard. GU (10) Bladder soft and nontender. No foley catheter present. Good hygiene, urine clear yellow, odorless and continent. Psychosocial (14) Respiratory (7) Lung sound clear on auscultation Respiration even and non labored Rest/ Exercise (11) Patient is able to perform ADL’s however needs supervision since patient is at risk for falls. Patient is ambulatory with walker. Misc. Eyes: No masses nor lymph nodes palpable. Thyroid regular, non palpable Happy affect Patient not oriented but verbal. Initiate conversation with health care professionals and family members Sclerae clear, brown iris, glasses Mouth: tongue moist and midline denture for lower teeth nose: Skin intact, no drainage, septum midline Ears: no aid needed, no drainage, no tenderness. Concept Map (TEMPLATE) PLAN OF CARE Priority Nursing Diagnosis #2 Decreased Cardiac output, related to increased vascular resistance, evidence by high BP(169/98) and hyperlipidemia. Priority Nursing Diagnosis #1 Costipation related to the use of Iron supplement and other drugs, evidenced by black tarry stools and pain in defecation. Outcome/Goal #1 The patient will have a soft formed stool or shows no signs of discomfort upon defecation by the end of the shift. Intervention #1 • • • • Outcome/Goal #1 Patient BP will maintain 130-140 systolic throughout the shift. Encourage fluids and fibers Encourage ambulation Assess bowel sounds Stool softner/ laxative as indicated. At Risk Dx.for fall and injury related to the usage of walker and lack of balance. Interventions # 2 • • • • Evaluation #1 Evaluation #2 Interventions were successful. Upon defecation the patient did not experience pain nor discomfort. Stool was still compact, but softer than previous one. Interventions were successful. Blood pressure decreased from 168/98 to 137/89 and it was maintained throughout the shift. At Risk Outcomes/ Goal Patient will have safety needs met and supervision throughout their stay. • • • • At Risk Interventions Encourage patient to call for help Place call light within reach Place bed in the lowest position Place fall precautions • mats, nonslip socks/shoes • bed alarm • night light • no clusters or mess in the room. Assess and document vital signs every 4 hours Check laboratory data Educate patient on dietary restriction Give Hypertension medication (metaprolol) At Risk Evaluation Plan Interventions were successful Patient did not suffer a fall during the entire shift.