Nursing Concept Map NURS 121L-A (2-20) PDF

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NURS 121L-A Concept Map Erickson’s Developmental Stage Related to pt. & Cite References (1) Generativity vs stagnation: seventh of stage of development. This stage takes place during during middle adulthood (ages 40 to 65 yrs). By failing to find a way to contribute they become stagnant and feel unproductive. They feel disconnected or uninvolved with their community. The patient is stagnant because thye don’t have many friends or is engaged in the community due to the language barrier of not speaking English and also due to health issues and pain.

Student Name: Shameka Pitts Instructor: Professor Celeste Patient Education (In Pt.) & Discharge Planning (home needs) iNiIIn Patient: Educate patient on the importance of having a healthy diet and refer them to a nutritionist. Explain gastritis and the signs and symptoms and how diet and exercise is important. Discharge planning: Educate patient on the food that will help not to irritate the stomach due to the gastritis. Educate the patient on keeping hydrated and seeking medical attention if they cant eat or drink or itf they have frequent or long standing abdominal pain.

History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).

Medical History

Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) The patient isn’t fluent in English and is Cambodian and has her uncle as a translator. She has no health insurance, Has her uncle for family support. She is catholic.She is unemployed.

Patient has gastritis as evidenced by abdominal pain and a refusal to eat or drink. Gastristis is a sudden inflammation or swelling in the lining of the stomach

Surgical History

No previous surgery history. Chief Complaint

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

hbg

Test

12-16

2/8/21

Current Value 9.1

wbc

500010000 3.5-5

2/8/21

11,150

2/8/21

4.8

37%47%

2/8/21

35%

potassium hematocrit

Norms

Date

NURS 121L-A Rev. 2-20

(1) Name: Chanthavy Chhet Age:46 Gender: Female Code Status: Full Code DPOA: N/a Living Will: N/a

Abdominal discomfort. Pt has non verbal communication. Not eating or drinking anything.

Admitting Diagnosis Dehydration and gastritis.

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

Dose

tylenol

500m g

RT

Freq.

MOA

RN Considerations

prn

oral

Trouble breathing, dizziness

Onset/ Peak/ Duration (Insulin) 10-60min 60-120min

Social History Pt doesn’t speak fluent English has social support. Doesn’t drink or smoke.

Priority nursing diagnosis #1 acute pain related to inflammation of the stomach as evidenced by abd minal discomfort.

Vital Signs (4) T: 99.4 P:92 R:18 02:98% BP:102/82, 90/64 standing

Nutrition/Hydration (8) Dehydrated, hasn’t eaten or drank anything.

Neurological (5) A&O X4 Pain: 6/10 Sensation normal

Cardiovascular (6) Normal heart sounds and respiration. Skin is warm and dry.

GI (9) Low urine output. Tender abdomen. Last BM 3 days ago

GU (10) Urine is cloudy and amber. Decreased urine activity

Respiratory (7) Breath sounds normal. 02: 98% No cough No nausea or vomiting

Outcome/Goal #2 This patient will increase fluid intake by 350ml. Integumentary (12) Skin is intact, no obvious bruises. Warm and dry.

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Endocrine (13) No thyroid issues. No hormone issues No steroid usage No diabetes

Interventions #1 Offer patient food. If pt still wont eat think about ng tube Administer pain medication. Go over diet so that patient will eat Assessment/ Evaluation #1 foods that wont upset their stomach. Patient met goal by eating jello, and pain was ble to be reduced by giving Tylenol.

PC Outcomes/Goal Hydrate the patient to combat dehydration and impaired mobility. Potential Complications/ at risk for At risk for dehydration At risk for impaired mobility

NURS 121L-A Rev. 2-20

Impaired mobility as evidenced by dehydryation.

Rest/ Exercise (11) No exercise , and hasn’t rested well due to abdominal pain.

Outcome/Goal #1 Patient will be able to reduce abdominal pain by end of shift and will be able to eat one meal.

Priority nursing diagnosis #2

Psychosocial (14) High school education. Mood is anxious. Doesn’t understand English well. No drug use.

Musculoskeletal No broken or displaced bones or muscles.

Assessment/ Evaluation #2 Patient met the goal by eating ice chips but the nurse also had to administer fluids through an iv so the dehydration wouldn’t go further.

PC Interventions Assess patient for fall risk and make sure there are safety precautions in place.

Interventions # 2 Offer water frequently. Give iv fluids if pt still refuses to drink. Offer the patient ice chips. Talk to their family to try to see if they can convince them to drink more to lower dehydration.

PC Evaluation Plan Patient was able to avoid any fall injuries or incidents so the goal was met. Patient was able to be fully hydrated at the end of shift....