Concept Map 2 Draft - course work PDF

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Concept Map Student Name: Hannah Moos Instructor: Ellen Lloyd

Erickson’s Developmental Stage Related to pt and how meets criteria: This patient is in generativity vs. stagnation This patient had fallen into the stagnation phase of life before the stroke. She had been separated for 13 years from her husband. She has had multiple brain injuries without skull fracture which has caused stagnation in her life.

Patient Education (In Pt.) & Discharge Planning (home needs)

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1). Admitting diagnosis: Nontraumatic subarachnoid hemorrhage Patho: A vessel ruptures and bleeds into the brain. This puts pressure and blood on the brain as the blood accumulates. This can be caused by a weakened vessel such as in an aneurysm.

S&S: Discharge Consults: 1. 2. 3.

(McLeod, 2018)

Must have 3

Diagnostic tests:

Proposed treatment: Cultural considerations, ethnicity, occupation, religion, family support, insurance. (Lewis et al., 2014)

Family/support: separated for 13 years married for 40, lives with daughter and daughter boyfriend

(Lewis, Bucher, Heitkemper, Harding, Kwong, & Roberts, 2014)

Culture/ethnicity: White Socioeconomic status: semi-retired 3 Psychological concerns: depression, stress, loneliness

Chief Complaint

Patient Information Diagnostic Test/ Lab Results with dates and Normal Ranges (3)

Test

Norms

Date

Stroke and Respiratory Distress

Name: N.S. Age: 58 Gender: Female Code Status: Full DPOA: N/A Living Will: N/A

Current Value

Medical History and how does it affect current diagnosis:  Brain Injury, Without skull fracture  Confusion  Hypertension  Neurological Symptoms

Admitting Diagnosis

(Lewis et al., 2014) Surgical History

Nontraumatic subarachnoid hemorrhage Cognitive Communication Deficit Dysphagia following nontraumatic subarachnoid hemorrhage Impaired mobility Acute-On-Chronic Respiratory Failure

 

Brain Surgery Colon Surgery Social History

 Medical Management/ Orders/ Medications & Allergies (2)

(Fischbach & Dunning, 2014)

Name

Dose

RT

Freq.

MOA

Docusate sodium

100 mg

Tube

Daily

Stool softener

(Micromedex, 2019)

RN Considerations Monitor electrolytes

Side Effects Abdominal cramps

Identify Complications associated with present illness. (2 at risk NANDA)

Priority nursing diagnosis #1

Vital Signs (4)

Neurological (5)

Cardiovascular (6)

BP – 108/63 HR 82 BPM RR19 BPM Temp 98.1 Temporal SPO2 95% Room Air

Wakes to voice Follows simple commands inconsistently

Normal rate Normal rhythm

Priority nursing diagnosis #2

Trach Placed – no secretions CTAB without wheeze Crackles

GI (9)

GU (10)

Rest/ Exercise (11)

Soft Nontender Nondistended

Foley in place

Patient nonmobile

Nutrition/Hydration (8) G-Tube

Respiratory (7)

Outcome/Goal #2

Outcome/Goal #1

Integumentary (12)

Endocrine (13)

No rash Warm/dry No edema or cyanosis Mittens in place Interventions #1 1. Must 2. Have 3. Four 4. Interventions (Carpenito, 2013)

N/A

Psychosocial (14)

Misc. (Ht/Wt)

N/A

Height: 5’5.98 Weight: 67.6 kg BMI 24.06 Allergy to statins

Assessment/ Evaluation #1

Assessment/ Evaluation #2

Goal met/not met?

Goal met/not met?

PC Outcomes/Goal

PC Interventions 1. Must 2. Have 3. Four 4. Interventions (Carpenito, 2013)

Potential Complications/ at risk for:

Interventions # 2 1. Must 2. Have 3. Four 4. Interventions (Carpenito, 2013)

PC Evaluation Plan Goal met/not met?...