Concept Map With Nursing Notes Documentations of Mary Jones PDF

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Interactive case study...

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Completion Instructions for Course Point+ Interactive Case Studies After completing the assigned interactive case study consider the patient vignette presented and complete the concept map by assigning the highest priority nursing diagnoses with supporting assessment criteria presented. On page 2, rank each nursing diagnosis identified on the concept map in the order of priority. Identify the appropriate patient outcomes using the SMART goal mnemonic. Each outcome must include each of the following characteristics: S – specific to the nursing diagnosis M – measurable, within the wording of the outcome how will a nurse measure progress (or regress) A – attainable – much be realistic for the patient situation R – relevant to the patient and his/her values T – time based – must note at what time interval the outcome will be measured Provide specific nursing interventions (independent and interdependent) that appropriate to attain the desired outcomes Provide the science-based rationale (with citations to the textbook) to support the use of the interventions.

CONCEPT MAP Nursing Diagnosis

Nursing Diagnosis

Fatigue r/t disease process AEB patient complains of tiredness, muscle weaknesses, and blurry vision. Subjective Data:

Impaired physical mobility r/t disease process AEB patient reports of tiredness/ muscles weakness and imbalance.

Subjective Data:

Patient complains ofPatient tiredness, muscle of tiredness, muscle complains weakness, body imbalance, andbody blurry weakness, imbalance, and blurry vision. vision. Objective Data:

Objective Data:

Period of incontinence, Resp 26,inBP Alteration gait, difficulty turning, 150/ 78, HR 108. Pt appears lethargic uncoordinated movement, resp 26, BP and loss of concentration 150/ .78, HR 108.

Reason for Seeking Health Care (Admitting Diagnosis) MULTIPLE SCLEROSIS

Nursing Diagnosis Deficiency knowledge r/t the diseases process AEB patient. states she does know why she is getting so weak and tired. Subjective Data:

Patient indicates he does not know she is getting shacky and so tired.

Objective Data:

The patient does not understand what multiple sclerosis and its signs is and symptom.

Risk for injury related to the physical barrier and diagnostic test.

Subjective Data:

Patient complains of muscles weakness and she cannot get her balance.

Objective Data:

Patient has unsteady gait and using furniture and wall to walk to the bathroom.

PLAN OF CARE PRIORITY #1 Nursing Diagnosis: Fatigue r/t the disease process AEB patient complains of tiredness, muscle

weaknesses, and blurry vision. Intervention (s) The nurse will

Rationale

Provide adequate rest and period

Rest and activity should be balance in fatigue patient.

Pharmacological /nonpharmacological

Medication and repositioning will decrease the pain.

Medication and repositioning will decrease the pain

Evaluate the Pt after 1 hour to see if med is effective

Decrease environmental disturbance

That will promote rest and decrease fatigue

Expected Outcome: The patient will report an increase energy to perform routine activity by the end of the shift. PRIORITY #2 Nursing Diagnosis: Impaired physical mobility r/t disease process AEB patient reports of tiredness/ muscles weakness and imbalance. Intervention (s) The nurse will Assess for neurological statue and assist with transfer from the bed to bathroom, Perform passive range of motion as tolerated

Rationale To prevent fall. To promote joint mobility and prevent DVT

Encouraged low pace exercise

To promote mobility.

Refer Pt to physical therapy for consultant

To promote muscles strength and mobility

Expected Outcome: The patient will demonstrate increase mobility during the hospital stay. PRIORITY #3 Nursing Diagnosis: Deficiency knowledge r/t the diseases process AEB patient. states she does know why she is getting very weeks and tired. Intervention (s) The nurse will

Rationale

Teach the patient about the multiple sclerosis and medication. Explain the testing procedure, self-catherization and maintaining a healthy lifestyle. Encourage the patient to drink plenty of fluid, eat protein, and increase fiber.

It is important to explain the test procedure including hand hygiene and diet to prevent complications. Good nutrition will promote wound healing and fiber will prevent constipation.

Voiding schedule and bowel training program

These will prevent incontinence

Awareness will lead to compliance

Expected Outcome: The patient will explain the pathophysiology of multiple sclerosis and what to expect before during and after the test. PRIORITY #4 Nursing Diagnosis: Risk for injury related to the physical barrier and diagnostic test. Intervention (s) The nurse will

Rationale

Ensure safety measure is in place: Bed in low position, call light within reach.

To prevent injury

Use safe mode of transportation.

To prevent injury

Remove rugs and clutters from patient way.

To prevent tripping and falling

Monitor neurological status and turn the patient every To prevent pressure ulcer two hours. Expected Outcome: The patient will not experience any infection while is staying in the hospital.

Narrative Nurse’s Note Date/Time 04/11/2021 0800 AM

04/11/2021 1000 AM

Nurse’s Note Signature Patient received in bed awake, alert and oriented x 3. Vital sign: Blood pressure is 156/78, Pulse 108, Respiration 26, temp 98.6, Sp02 95%, Patient reports pain 3/10. the capillary refill is 2 second. The patient reports muscles weakness, tiredness, blurry vision. Patient left in supine position with the head of the bed elevated at 30 degree. safety measures in place, Bed locked in lowest position, side rails up X 2 by hospital policy. Call light within REACH. ----------------------. M, Gilles, NSU/NS.

Patient teaching: Patient informed about the pathophysiology of multiple sclerosis including the signs and symptom of relapsing (MS), primary (MS), secondary (MS), and Progressive (MS). patient educated on how to perform intermittent self-catherization and maintain a healthy lifestyle change. safety measure in place. ------------------------------------------------------------------ M, Gilles, NSU/NS.

04/11/2021 1500 PM

Hand report is given: The nurse informed to continue monitor the surgical site, drainage, encourage of using incentive spirometer every hour, and range of motion.

Narrative Nurse’s Note Date/Time

Nurse’s Note

Signature...