Concept Care Map Vincent Brody COPD A+ PDF

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Summary

concept map
based on v sim patient
helene fuld
...

Description

Care Plan Concept Mapping Instructions EXAMPLE Virtual clinical Activity: Each student is required to produce a concept map for one of the vSim cases by the end of. The completed map should be uploaded to blackboard in the provided assignment shell. Instructions for the concept map are: 1. Identify the vSim case as the central concept in the middle of the page. 2. Add the relevant health concern or reason for seeking help. 3. From the main health concerns, add two significant priority nursing diagnoses within the provided shapes on the map template. 4. For each nursing diagnosis, list the subjective and objective data, identified from the vSim case that are associated with the nursing diagnosis. 5. List current information about medical diagnosis, risk factors, diagnostic test, treatments, and medications under the appropriate nursing diagnosis. 6. List nursing interventions for each diagnosis. Interventions include key areas of assessment that was done, procedures, teaching, and therapeutic communication. 7. Add the expected outcomes associated with the nursing interventions for each nursing diagnosis. 8. Finally draw lines between concepts to indicate relationships. Link the concepts and related data by different lines (e.g., arrows, straight or broken lines), depending on the nature of the relationship between concepts. On each line, use words such as: related to, contributed to, is necessary for; to explain the relationship between linked concepts. 9. Add two short- and long-term goals for each diagnosis and if each goal were met or unmet 10. Finally, if you use different colors on your map, develop a map key with codes to explain what each color and illustration represent. Example Map Key: Blue Lines: Priority diagnosis Met: Unmet:

Concept Care Plan Concept Mapping 224 Name:

Date : 9/13/2020

Priority Nsg Diagnosis # 1: Priority Nsg Diagnosis # 2: Ineffective Airway Clearance r/t pneumothorax as evidence by persistent cough. Subjective data:

Risk for Infection r/t chest tube insertion Possible Subjective data:

PT. stated “I think I need my medicine. I have a really bad cough.” PT stated “ This cough is killing me.” PT. c/o of pain on left side.

Pain, c/o SOB, chills, malaise Possible Objective data:

Objective data PT.EKG Sinus tachycardia Temp: 99 F, HR: 125. Pulse: is Present. B/P 145/87. Respiration: 36. AAOx4 SpO2: 89%. The chest is not moving very well. There are reduced breath sounds on the L side of chest. R side has normal breath sounds .

Elevated Temp, redness, , exudate ,odor, drainage on dressing Swelling Current information

Current information

Contributed to… OR Is necessary for….clicking here

Patient:

Contributed to… OR Is necessary for….

Medical diagnosis COPD

Risk factors PT. has a 50-year HX of smoking 2 packs a day. PT. has a barrel chest and clubbed fingers. This past year the PT. has had 2 exacerbations.

Diagnostic tests ABG , CBC , Chest X Ray EKG

Vincent Brody is a 67-year-old male admitted directly from the provider’s office several hours ago for exacerbation of their COPD. There are a few audible wheezes in the chest and a persistent cough PT. developed a L-sided pneumothorax.

Medical diagnosis: COPD

Risk factors: An open portal of entry at insertion site. Compromised skin integrity.

Diagnostic tests: Obtain and monitor CBC,ESR,CRP, Blood Cultures

Treatments:

Treatments Chest tube placement Monitor Vital Signs. Monitor for respiratory depression, monitor I&O and check pulmonary functions. Encourage use of incentive spirometer Monitor ABGs, CBC and EKG

Medications

ATB therapy per providers orders, Monitor VS

Medications: Morphine 2mg IV push, albuterol 2.5 in 3ml NS via NEB, Oxygen therapy to maintain above 92

IV of potassium chloride in D5% and NS infusing at 100 mL/hr in his right hand Morphine 2mg, IV push, prior to intubation Albuterol 2.5mg in 3ml NS via neb every 20 min X 3 doses Nsg interventions Nsg interventions

Nursing interventions:

Nursing interventions:

1. PT. cough will be decreased and NO s/s of SOB and maintain his Spo2 equal or above 92% by the end of the shift on 2 L of O2 for 24 hrs. Goal met

1. PT. to maintain temp no greater than 99.6 for 24hrs a/e by monitoring Vitals, and assessment of open area. Goal is met at this time.

2. PT. will remain cough free and S SOB. PT able to maintain Spo2 equal or to above 92% on room air upon discharged. Goal unmet due to PT. still being admitted.

2. PT. maintain insertion site free of infection as evidence by no exudate, redness, and/or odor for duration of stay in hospital. Goal unmet due to PT. still be admitted....