Final Concept Map NURS 208 PDF

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Patient Initials: S.D Gender/Age: F/81 Abstract Dementia is a general term that describes gradual cognitive decline and global intellectual disability (Pollard, 2020). There are five primary forms of dementia: Alzheimer’s, Lewy’s diffuse body disorder, Creutzfeldt-Jacob dementia, vascular dementia and frontotemporal dementia (Hall, 2020). Memory loss, judgement, and thinking and mood changes, actions, and communication skills are the indications of dementia (Hall, 2020). Cognitive function loss leads to the reduction in the abilities to accomplish simple and functional ADLs (Hall, 2020). Dementia, unlike delirium, is described by progressive, permanent cerebral dysfunction (Hall, 2020). Worldwide, 46.8 million people are expected to have dementia, and by 2050, the prevalence of dementia might double every 20 years to 115.4 million (Pollard, 2020). There are more than 500,000 Canadians affected by dementia now (Pollard, 2020). Of these, 71,000 are under age 65, and just 1 in 11 Canadians over 65 have dementia (Pollard, 2020).

Patient Initials: S.D Gender/Age: F/81 Clinical Data Collection Neurological/Mental Status Alert and oriented x3 Dementia CVA with R hemiplegia Calm & pleasant (@0800) Happy, laughing & making conversations (@1200) Appeared agitated midway V/S (@1545)

Genitourinary System Usage of beige briefs  Felt heavy – urinated in AM

Respiratory System @0815  RR – 14 breaths/min  No adventitious sounds upon auscultatio  No accessory muscles used  No respiratory distress  SpO2 – 97% on RA @1545  RR – 14 breaths/min  No adventitious sounds upon auscultatio  No accessory muscles used  No respiratory distress  SpO2 – 94% on RA

Musculoskeletal System Able to lift L arm as instructed Slight weakness, unable to lift R arm Able to lift legs with slight discomfort

Cardiovascular System @0815  BP – 126/83 mmHg  P – 60 bpm, regular, +2  No edema  No cyanosis @1545  BP – 131/69 mmHg  P – 66 bpm, regular +2  No edema  No cyanosis  No signs of chest pain Diagnosis/Medical History Primary – CVA with R hemiplegia Secondary – HTN, Dementia, Diabetes Advanced Directives – DNR – level 2

Gastrointestinal System No BM present @0800 No distension upon palpation Bowl sounds present in all 4 quadrants upon au @0815 – ate 100% of meals, 500 mL of fluids @1215 – ate 100% of meals, 250 mL of fluids

Pain Assessment Observed no pain Observed no grimacing, no moaning

Treatments/Nursing Interventions

Integumentary System Dry skin  coconut oil applied Small scratch on back, no open wound present @0815  T – 35.1℃ tympanic @1545  T – 35.7℃ tympanic

Patient Initials: S.D Gender/Age: F/81

Ears, Eyes, Nose, Throat (EENT) Observed no drainage from ears/eyes/nose Partial blindness (in R eye) Partial hearing impaired

Interventions Provide a calm environment. Talk to client using simple, concrete nouns in positive terms to reduce anxiety

Diet – pureed diet, thin fluids, diabetic Elimination – Incontinent, No BM in AM Activity/Safety – complete care, bed bound Medications ASA Chew – 1 Tab PO daily amLODIPine – 10 mg Atovasatin – 20 mg (1 Tab PO evening) Candesartan – 8 mg (2 Tab PO daily) Citalopram – 20 mg (1 Tab PO daily) Metoprolol – 5o mg (1 Tab PO 2x daily) risperDONE – 0.5 mg (1Tab PO 2x daily) Senokot – 8.6 mg (2 Tab PO 2x daily) Terazosin – 5 mg (1 Tab PO @bedtime) TrazoDONE – 50 mg (1/2 Tab PO @bedtime) Nitro Patch – 0.4 mg/hr (1 patch in the morning and removed @bedtime) Psychosocial/Spiritual Widowed No family noted on file

Interventions

Endocrine/Reproductive System Diabetic?

Interventions

Implement measures to promote independence but intervene when the patient cannot function.

Frequently orient client to place, time and situation.

Guide patient to the placement of food on plate since partially vision impaired

Ensure call bell is within reach.

Expected Outcomes Expected Outcomes Client would be a little independent in bed bath within 4 weeks.

Expected Outcomes Patient remains content and free from harm within 4 weeks.

Nursing Dx Self-care deficit related to cognitive impairment.3 Medical DX

Nursing Dx

Dementia

Chronic confusion related to alteration in structure/function of brain tissue.3

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Pathophysiology Caused by damage to/loss of nerve cells & their connections in the brain. 2 Affects memory, typically caused by anatomic changes in the brain, has slower onset & is generally irreversible. 2 Edition. [Pageburstls]. Retrieved

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Clinical Manifestations

Memory loss1 Cognitive impairment 1 Mood changes1 disorientation1 Agitation/aggression1 Hallucinations (psychosis)/anxiety1 Chronic confusion1

Client will not experience physical injury within 4 weeks.

Nursing Dx Risk for trauma due to disorientation.3

Risk Factors References 1  Age  Genetics/family hx1 Hall, P.P.W.D.P.S.B.A.A.P.  Smoking & alcohol use1 A. Canadian Fundamentals of impairment1  Mild cognitive Nursing. [Pageburstls]. Retrieved from https://pageburstls.elsevier.com #/books/9781771721134/ (1)

Pollard, S.J.M.H. C. Varcarolis's Canadian Psychiatric Mental Health Nursing, Canadian from https://pageburstls.elsevier.com/#/books/9781771721400/ (2)

Patient Initials: S.D Gender/Age: F/81 Herdman, T. H., & North American Nursing Diagnosis Association. (2018). NANDA-I nursing diagnoses: Definitions & classification, 2018-2020. Oxford: Wiley-Blackwell. (3)...