concept mapping and care plan

Patient Case #4

Patient: Vernon Russell

Diagnosis: Right-sided stroke (mild left hemiplegia)

Brief Summary
:

Vernon Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday. The patient is nothing by mouth except medications. Chest-x-ray confirmed possible aspiration pneumonia on the right side.

Medications:

· Losartan 50 mg PO BID

· Aspirin 81 mg PO daily

· Metformin 500 mg PO BID

· Chlorthalidone 25 mg PO daily

Orders:

· Vital signs and neuro checks every 4 hours

· Activity: Up to chair, up to the bathroom with assistance

· Nothing by mouth except medications until swallow study completed tomorrow

· Speech therapist swallow study

· Fall risk assessment

· Labs: CBC, chemistry panel, and prothrombin time

· Bedside blood glucose twice a day

SBAR Report
:

S: Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had a head CT and received thrombolytic therapy in the ED. He is nothing by mouth except for medications until the speech therapist has completed a video swallow study, which is scheduled for later this morning. He is scheduled for physical therapy later today.

B: Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise.

A: We have already checked his blood glucose level this morning. His vital signs have been stable and he slept well last night. He was able to get up to go to the bathroom with the use of a walker. His neurological checks are stable and he continues to have mild left hemiplegia. His hand grasps are almost equal but a little weaker on the left side. His pupils are equal and react to light. Swallow reflex is intact but impaired. He is oriented x2. Patient is slow to respond and noted to have some periods of slurred or delayed speech. I have already done a Morse Fall Risk assessment with a total high risk score of 60. Fall precautions implemented. Upon bedside RN swallow evaluation, the patient was noted to have frequent coughing when given a small sip of water. Chest x-ray done in the ED reveals that the patient has right-sided pneumonia, possibly due to aspiration.

R: You should do a vital signs assessment, perform a neurological assessment, and talk about safety with Mr. Russell. His morning medications are up and should be administered with caution. Maintain NPO status until video swallow performed. Patient was able to stand on side of bed with physical therapist, but weakness noted. Patient unable to take steps. Continue fall and aspiration precautions.

Patient Case #2

Patient: Edith Jacobson

Diagnosis: Left hip fracture

Brief Summary
:

Edith Jacobson is an 85-year-old white female with a history of osteoporosis. She lives at home by herself where she fell and broke her left hip yesterday evening, after having complaints of dizziness, weakness, and fatigue. She is scheduled to have surgery in 2 days.

Medications:

· Enoxaparin sodium 40 mg SQ daily

· Docusate sodium 100 mg PO daily

· Morphine sulfate 4 mg IV q4h prn for pain

· Metoprolol 25 mg PO BID

· Furosemide 20mg PO daily

Orders:

· Vital signs every 4 hours

· Activity: Bed rest

· Anti-embolism stockings on both legs (knee-length)

SBAR Report
:

S: Mrs. Jacobson is an 85-year-old white female who was admitted last evening after falling and fracturing her hip. X-rays have been taken and show left intertrochanteric hip fracture. Mrs. Jacobson is scheduled for surgery in 2 days.

B: Mrs. Jacobson has a 10-year history of osteoporosis and was newly diagnosed with congestive heart failure last year. Her daughter reports that recently Mrs. Jacobson has been having dizzy spells, fatigue, and weakness. Mrs. Jacobson lives alone and is usually able to perform all her ADLs independently. She does have a cane at home but often times refuses to use it because she “doesn’t think she needs it”. Mrs. Jacobson is usually pretty active, but has been much more sedentary lately due to increasing weakness and fatigue due to medication non-compliance with her heart failure medications.

A: Mrs. Jacobson is AOx4 and her vital signs are stable. Her pain level is currently a 7 out of 10, and she describes is as “throbbing and aching” in her left hip. Often times Mrs. Jacobson will moan or cry out in pain, especially whenever she needs to be moved in bed. She is very resistant to let anyone touch or move her left leg. The skin is intact; color and sensation around the hip area are within normal limits. A Morse Fall Scale assessment was completed on admission, and her score was 45. Fall precautions were implemented. Mrs. Jacobson has limited ROM in her left hip and her muscle strength in her left lower extremity is weak at a 2/5. Mrs. Jacobson has been having some episodes of urinary and bowel incontinence since being admitted to the hospital. She frequently needs to be reminded that she cannot get out of bed due to her activity restriction.

R: You will need to reposition Mrs. Jacobson as she needs to be turned every 2 hours. You should perform a focused musculoskeletal assessment, reinforce safety, and provide patient education on fall risk. Assess her pain level and medicate for pain if needed.

NRG5000 Theoretical Foundations of Nursing

Dr. Lisa Capps, Faculty

1

Concept Map and Care Plan (Clinical Assignment #2) Grading Rubric

Student Name: __________________________________________________

Description

Points Received/

Total Points Possible

Comments

Diagnosis #1

Diagnosis #2

Totals

Patient Information and Health Assessments
· Complete patient demographics, health assessments, and interventions

____/ 3

Pharmacology:
· Complete& accurate description of current meds, including purpose for this patient, side effects, and all other data listed in chart

____/ 3

Pathophysiology:
· Includes “signs and symptoms”
· Includes APA references cited

____/ 3

Nursing Diagnosis (Include ALL 2 Dx):
· Reflects the primary diagnosis
· Appropriate for patient scenario as well as priority level
· In acceptable NANDA format
· Includes all parts stem, R/T, AEB
· Only 1 ‘Risk For’ diagnosis can be used

____/ 3

Provided 2 nursing diagnoses: 2 points per diagnosis

____/ 4

Assessment:
· Appropriate for chosen diagnosis
· Includes objective & subjective historical support diagnosing data

____/3

+ ____/3

= ____/ 6

Patient Outcomes:
· Include at least 2 outcomes for each diagnosis
· Specific to the patient diagnosis
· Contains the following 4 criteria:
measurable, attainable, realistic, and timed
· All criteria present for patient’s expected outcome

____/3

+ ____/3

= ____/ 6

Intervention/Implementation:
· Include at least 3 nursing interventions for each patient outcome
· Includes interventions/ nursing actions directly relating to pt. outcomes
· Specific in action, frequency and contain rationale
· # of interventions is appropriate to help pt./ family meet their outcomes

____/3

+ ____/3

= ____/ 6

Evaluation:
· Must have an evaluation statement written for each patient outcome
· Includes all data that is listed as criteria in outcomes
· Outcomes are determined to be met, partially met, or not met
· If outcome was not met/ partially met, plan of care is revised/ continued & new evaluation date/time is set

____/3

+ ____/3

= ____/ 6

Total Points: ____/ 40

PatientCase Scenario #1

Chris Parrish

Patient: Christopher Parrish

Diagnosis: Cystic fibrosis, weight loss, and fatigue

Brief Summary
:

Christopher Parrish is an 18-year-old adolescent male who is hospitalized for management of cystic fibrosis with weakness and weight loss. He reports fatigue, and he has had a recent 6 kg (13.2 lb) weight loss. He was diagnosed with cystic fibrosis as an infant and has had multiple hospitalizations for respiratory and nutritional support. A nasogastric (NG) tube has been placed for feedings.

Medications:

· Pancrelipase supplement 5 capsules PO QID with meals and at start of nightly tube feeding

· Multivitamin 2 tabs PO daily

· Potassium chloride 40 mEq PO daily

Orders:

· Vital signs every 4 hours

· Daily intake and output, and weight

· Chest X-ray: AP and lateral tomorrow morning

· Insert nasogastric tube

· Nutrition consult

· Diet: High-fat, high-calorie, high-protein regular diet, supplement with high-protein snacks in between meals

· Promote tube feedings (1.5 kcal/mL) in nasogastric tube; administer 720 kcal over 8 hours at night (infuse via pump from 2200-0600)

SBAR
:

S: Christopher Parrish is an 19-year-old male who was admitted at 1900 today. His mother visited him at his college dormitory and was very concerned with his health; he seemed weak and had lost weight since she last saw him. She took him to see his primary care provider, and the provider admitted him and has ordered a tube feeding. An 8-French, 42-inch feeding tube was placed in his right nare about an hour ago, and x-ray just called and confirmed placement in the stomach. The pump is in his room. He is up to the bathroom prn; otherwise bed rest.

B: Christopher was diagnosed with cystic fibrosis as a child and has had frequent hospitalizations previously. He reports fatigue and has recently lost 6 kg (13.2 lb) after he registered at the local college and moved to live in a dormitory, one month ago. Chris’s mom was here earlier, but she is a single parent and has two younger boys, so she had to go home.

A: Christopher is awake and alert. His heart rate and rhythm are regular at 85 bpm. Breath sounds are fine with a respiratory rate at 18/min and his SpO2 saturation is 98% on room air. His color is a bit pale. Blood pressure is 118/78 mm Hg. He reports no pain and states he’s not had much appetite the past few weeks. His skin turgor is > 3 seconds and his mucous membranes are dry. His belly is flat and nontender. Bowel sounds are normoactive. Chris is noted to have a persistent productive cough, and his sputum is noted to be thick and yellow in color. Chris tends to get short of breath with any strenuous activity. He was noted to become short of breath, with an increase in RR to 26 bpm, after walking in the hallway for about 10 minutes. His potassium level this morning was low at 3.2 mEq/L.

R: Christopher is due for vital signs and assessment. The tube feeding just arrived, and you will need to start it on the pump. He needs 720 kilocalories over 8 hours overnight. His regular diet is high calorie, high fat, but he wasn’t too hungry this evening; just had a bit of his chocolate shake. You will need to give his pancreatic enzymes orally before you start the tube feeding. You should also assess his diet and reinforce patient education on nutrition.

Patient Case #3

Patient: Rashid Ahmed

Diagnosis: Dehydration and hypokalemia

Brief Summary
:

Rashid Ahmed is a 50-year-old Middle Eastern male who was admitted this morning to the medical unit with a diagnosis of dehydration and hypokalemia. He has been experiencing nausea, vomiting, and diarrhea for the past 48 hours after eating at a local restaurant three days ago.

Medications:

· Trimethoprim/Sulfamethoxazole 160/800 mg PO q12h

· Potassium chloride (KCL) 40 mEq PO once

· Ondansetron 4 mg IV push q6h prn for nausea

· Lisinopril 5mg PO daily

· Atorvastatin 10mg PO nightly

Orders:

· Vital signs every 4 hours and prn

· Daily weights

· Activity: Up ad lib with assistance x1

· Diet: Clear liquids, progress to regular as tolerated

· IV: 1000 mL dextrose 5% in normal saline with 20 mEq KCL at 125 mL/hr

· Intake and output, record every 8 hours

SBAR Report
:

S: Mr. Rashid Ahmed is a 50-year-old Middle Eastern male who was admitted to our unit at 0600 this morning after being admitted to the ED at 0400 with a diagnosis of dehydration and hypokalemia. We are monitoring his fluid and electrolyte status closely. I have just received admission orders.

B: Three days ago, he developed abdominal cramping, nausea, vomiting, and severe diarrhea 12 hours after eating lunch at a local restaurant. The symptoms have continued for the past 2 days, and food and fluid intake has been minimal to none since the symptoms began. Last night he nearly passed out while going to the bathroom around 0300. Mr. Ahmed was brought to the ED by his wife, and reported dizziness, weakness, and continued nausea. He received 4 mg ondansetron IV for nausea in the ED. Lab work was drawn and is available in the patient chart, and urine and stool samples have been sent to the lab. Mr. Ahmed’s only medical history includes hypertension and hyperlipidemia.

A: Mr. Ahmed is drowsy but oriented x 3, appears ill, and is irritable. He reports having a headache, which he rates a 4 on a scale of 0–10, but he hasn’t wanted anything for it. Admission weight was 73 kg (162 lb), which the patient reports to be about 4.5 kg (10 lb) less than usual. Vital signs were obtained on admission, including orthostatic blood pressure readings which were positive. Patient had drop in BP from 135/70 while lying down to 105/55 once he stood up. He reports dizziness. Heart rate is tachycardic and irregular. Patient also noted to have a 100.4 degree temperature. He has only taken a few ice chips since admission due to his nausea. The patient had one small liquid stool in the ER. He has not voided or experienced emesis since admission. An IV bolus has been completed and now D5NS IV fluids are running at 125 mL/hr.

R: Mr. Ahmed has new IV orders that need to be initiated. You will need to start him on oral antibiotics and potassium when nausea resolves. Provide patient education on safety, his prescribed medications, and intake and output measurement.

Concept Mapping

Patient initials, age, gender and admitting diagnosis

Nursing diagnosis

Related to

As Evidence by

Nursing diagnosis
Related to
As Evidence by

Outcomes

Assessment

Signs / Symptoms

Subjective / Objective

Outcomes
Assessment
Signs / Symptoms
Subjective / Objective

Interventions

Interventions

Evaluation of Interventions / Outcomes

Medication

Dose, Route & Frequency

Classification

Purpose / Mechanism of Action

Significant Side Effects / Adverse Reactions

Nursing Implications

Pathophysiological Discussion

1. APA format (citations and references)

2. Discuss the disease process: etiology, epidemiology, and pathophysiologic mechanism

3. Identify common complications that may occur with the alterations or treatment modalities

4. Patient’s overall prognosis