Patient Concept Map

Patient Concept Map

1. Choose an individual for whom you have cared in the clinical setting.
2. Create a concept map based on the complete physical assessment you performed while providing care using the provided powerpoint template.
   1. Components of the concept mapIndividual’s information )
      1. Age
      2. Medical diagnosis
      3. A brief review of the underlying pathophysiology

*List what functional changes are happening

*List process that initiated and maintained disorder or disease

1. Assessment Data
   1. Include all assessment data, not simply information that supports the selected nursing diagnoses

Inspect

Palpation

Percussion

Auscultate

Neurological Exam

How to do a concept map for nursing

Patient Concept Map

• Nursing Diagnoses )
  1. Select three nursing diagnoses to addresses
     1. One must be an actual problem
     2. One must address a psychosocial need
     3. The final must be a high priority for the individual
  2. Linkages Within and Between Diagnoses ()
     1. The concept map demonstrates the relationship within and between the nursing diagnoses.
  3. Planning
     1. Prioritize diagnoses to reflect the needs of the individual
     2. Set realistic outcome measurement
  4. Implementation
     1. Interventions are individualized for patient-provider rationale
     2. Interventions support the achievement of selected outcome measurements-provide rationale

• Evaluation of Outcomes
  1. Determine if outcomes were met.
  2. Provide evidence that supports that determination.
  3. Describe what changes, if any, are needed to promote expected outcomes in the future.
• Safety-Communication-Infection Control
  1. specific elements of communication used when providing care,
  2. safety concerns related to the individual for whom you cared, and
  3. infection control practices followed while caring for this patient.

HISTORY OF PRESENT PROBLEM

Patient Concept Map

The patient is Joan Walker; she is 84 years old. She has had a productive cough which is green in colour for the past 4 days. Her PCP (primary care provider) started her on Prednisone 40 mg daily and Azithromycin (Zithromax) 250 mg PO for 5 days which she started 3 days ago. She has had intermittent chills, a fever last night of 102F/38.9C and has increased shortness of breath especially in the evening and during the night. She is using her albuterol inhaler about every 1-2 hours which does not seem to be working. She called 911 and is now in your ER and you are the nurse responsible for her care.

PERSONAL/SOCIAL HISTORY

Joan is a widow for the past 6 months, after being married for 64 years and is currently living in an SNF (skilled nursing facility). Taught as an elementary school teacher for over 30 years in the local community. She is active in her church and called her pastor who can with her to the ER. You walked in as the pastor asked Joan if she would like to pray. Joan replied to the pastor “yes please I feel that this may be the beginning of the end for me”

Current vital signs T: 103.2F/39.6, P 110 regular, R 30 laboured and using accessory muscles, BP 178/96, O2 sat 86% on 6 litres of oxygen via nasal cannula, P-Q-R-S-T Pain Assessment Provoking: deep and shallow breathing, Quality: ache, Radiation: generalized pain over the right side of chest no radiation, Severity: 3/10, Timing: Intermittent last a few seconds

CURRENT ASSESSMENT:

Patient Concept Map

General Appearance: appears anxious and in distress, barrel chest observed

Respiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally anterior and posterior with scattered expiratory wheezing

Cardiac: Pale hot and dry, no oedema, heart sounds regular S1 S2 pulse strong equal with palpation at radial/pedal/post-tibial landmarks

Neuro: Alert and orientated to person, place, time, and situation (x4)

GI: Abdomen soft non-tender bowel sounds audible per auscultation in all 4 quadrants

GU: Voiding without difficulty, urine clear

Skin: intact turgor elastic and no tenting visible

Fluid and Electrolytes/Lab/ Diagnostic results

Chest x-ray: left lower lobe infiltrate with hypoventilation present in both lung fields

Lab: WBC (4.5-11.0) hers: current is 14.5 prior was 8.2

Hgb (12-16g/dL) current 13.3 prior was 12.8

Platelets (150-450×103/ul) current 217 prior was 298

Neutrophil % (42-72) current 92 prior was 75

Band for (3-5%) current 5 prior was 1

Here is more lab data:

Basic Metabolic Pane. (BMP):

Sodium (135-145 mEq/L) current 138 prior 142

Potassium (3.5-mEq/L5) current 3.9 prior 3.8

CO2 (Bicarb) (21-31mmol/L) current 35 prior 31

Glucose (70-110 mg/dL) current 112 prior 102

BUN (7-25 mg/dL) current 32 prior 28

Creatinine (0.6-1.2) current 1.2 prior 1.0

Lactate (0.5-2.2 mmol/L) current 3.2 prior NA

ARTERIAL BLOOD GAS (ABG):

pH (7.35-7.45) current 7.25

pCO2 (35-45) current 68

pO2 (80-100) current 52

HCO3 (bicarb) (18-26) current 36

O2 sat (>92%) current 84%

What is the ABG interpretation?

HERE IS THE PATIENT’S MEDICATION

Lorazepam 2.5 mg every 6 hours as needed for anxiety

Atorvastatin 600 mg twice a day

Enalapril 10 mg daily

Albuterol MDI 2 puffs every 4 hours PRN

Salmeterol/fluticasone Diskus (Advair) 1 puff every 12 hours

Triamterene-HCTA (Dyazide) 1 tablet daily