Concept Map / care plan for nursing PDF

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Care plan and concept map for nursing...

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Clinical Concept Map

Name: Jessica Canez

Instructions: -Assessment data may be placed in more than one box. Med Cards as needed.

Circulation BP: 108/82 P: 62 Temp: 36.8 C Apical pulse: WNL Rate: Rhythm: WNL S1, S2 noted, regular Peripheral pulses in extremities

Food/Fluid

Low-fat, gluten free, raw vegetables High protein and supplemental vitamins- reduce inflammation and supplement vitamin D, fiber

Elimination

Abdomen: soft, nontender Affects bowels: constipation or diarrhea resulting in hypoactive or hyperactive bowel sounds Bladder: spastic bladder (incontinence) flaccid bladder (urinary frequency) risk for UTIs, renal stones

Activity/Rest Fatigue, weakness, malaise, feeling drained Quality sleep will be vital for overall health

Hygiene/Safety Decreased vision, coordination, sensory measures Fall risk Immunizations Swallow study/ speech

Updated 12.21.21/df

Respiration/Oxygenation Lungs clear to auscultation bilaterally, no crackles, stridor, or wheezing RR: 16 bpm O2 Sat: 98% RA

Reason for Health Care (Medical Diagnosis/Procedure) Multiple Sclerosis – a progressive autoimmune disease that causes a decrease in nerve transmission in the CNS. Patho: The immune system attacks the myelin sheath of axon nerve cells causing patients to experience sensory and motor issues that come and go. Diagnostic & labs: MRI will view any plaques, lumbar puncture. Monitor increased blood serum levels, increased WBC Risk factors: genetic, smoking, female sex, infections such as Epstein-Barr virus, obesity, lack of sunlight/vitamin D

Teaching/Learning/Support/ DC Plan Ways to avoid fatigue Encourage independence Smoking cessation Avoid extreme hot and cold Teach good exercise, rest, nutrition Support groups

Psychosocial/ Emotional Adjustment Psychological problems such as anger, and depression Cognitive delays Memory recall delays Erectile dysfunction Decreased libido Painful intercourse Decreased lubrication

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Date: 05/05/2021 Integumentary Skin warm, dry, pink free from lesions and rashes May have edema

Pain/Comfort Tx: Corticosteroids- reduce edema and inflammation Muscle relaxants-spasms Anticholinergics- Bladder issues Anti Parkinson’s-fatigue Propranolol-tremors Gabapentin- Chronic neuropathic pain Physical therapy- relieve spasticity, increase coordination

Neurosensory Slurred speech, dysarthria (difficulty speaking) dysphagia Double or blurred vision, nystagmus, ataxia (uncontrollable body movements) Confusion or disorientation Decreased hearing Vertigo, tinnitus

Musculoskeletal Contractures, weakness, or paralysis of limbs Muscle spasticity, tremors, “Lhermitte’ sign- electric down body Growth & Development/ Ego Integrity Most pt are diagnosed between ages 20-50. This is during the intimacy vs isolation stage where most people are building long term relationships and discovering self

Clinical Concept Map Clinical Prioritizing Tool:

Name: Jessica Canez

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Date: 05/05/2021

1) From your information and assessment data-form a brief SBAR to give your instructor. 2) Identify at least four nursing issues supported by your assessment data 3) Pull supporting data from assessments and concept map to support your top four nursing issues. 4) Discuss and note the relationships between the four issues with your instructor. 5) Choose the two priority nursing diagnoses. 6) On the next page, write the 2 priority nursing diagnoses, interventions and short term goal

Impaired physical mobility r/t weakness, muscle spasticity, and paresis

Self-care deficit r/t emotional barriers, physical barriers, and lack of communication

Risk for injury r/t sensory, motor, visual, and communication impairments

Ineffective coping r/t uncertainty of progression of MS

Nursing Diagnosis Priority Nursing Diagnosis Updated 12.21.21/df

Interventions

Short Term Outcomes S.M.A.R.T.

Clinical Concept Map Impaired physical mobility r/t weakness, muscle spasticity, tremors, incoordination, and paresis as well as sensory-perception impairment

Name: Jessica Canez

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Pt

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Date: 05/05/2021

Assess for pain, falls, coping Assess ROM active and passive Educate and promote exercise, PT, good diet, and overall well being

Pt will ambulate Pt will perform as many ADLs independently Pt will increase exercise a little each week or as tolerated Pt will verbalize any

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Sexual dysfunction r/t emotional barriers, physical barriers, and lack of communication

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Encourage open communication with pt and partner

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Discuss decreased sensation, libido, and lubrication associated with MS As well as depression and medication side effects

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will

Pt will identify stressors Pt will discuss alternative, safe and satisfying sexual practices for self and partner Discuss any barriers Adapt sexual technique Discuss concerns with partner Pt will verbalize any concerns

Comments:______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ Instructor Signature________________________ Narrative: Updated 12.21.21/df

Clinical Concept Map

Name: Jessica Canez

Date: 05/05/2021

MS mostly affects the spinal cord, brainstem, and optic nerves. Pts present with weakness, tremors, and spasticity of extremities, fatigue, pain, mood changes, numbness, and loss of balance. However, their symptoms can come and go so it often takes quite a while before a diagnosis is reached. The goal for treatment since there is no cure is to delay progression and manage symptoms.

Updated 12.21.21/df

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Clinical Concept Map

Name: Jessica Canez

Date: 05/05/2021

References BS, P.A.P.R.M.P.F.A.G.P.R.E.F.P.S. R. (2017). Fundamentals of Nursing. https://online.vitalsource.com/#/books/9780323327404/. https://online.vitalsource.com/ Henderson, W. (2017, July 21). Multiple Sclerosis News Today. https://multiplesclerosisnewstoday.com/2017/07/21/nine-ways-multiple-sclerosisaffects-your-body-from-your-head-to-your-toes/?cn-reloaded=1 Lewis, S. L., Bucher, L., Heitkemper, M., Harding, M., Kwong, J., & Roberts, D. (2017). Medical Surgical Nursing (10th ed.) [VitalSource Bookshelf]. Mosby Inc. https://doi.org/https://online.vitalsource.com/#/books/9780323328524/ Mayo Clinic. (2020, June 12). Multiple sclerosis - symptoms and causes - mayo clinic. https://www.mayoclinic.org/diseases-conditions/multiplesclerosis/symptoms-causes/syc-20350269 Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care. (n.d.). https://online.vitalsource.com/#/books/9780323322249/. https://online.vitalsource.com/

Updated 12.21.21/df

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