ano 1NURS 356 Master (2)

Running Head: CONCEPT MAP 1 Concept Map Onyinye Onyekwelu Felician University Department of Prelicensure Nursing “ I declare on my honor that I have neither given nor received inappropriate aid on this paper”CONCEPT MAP 2 Vitals and lab and values BP 160/98 Pulse 83 Temp 97.7 Resp 20 Sp 02 94% Cr: 2.64 Glucose: 560 ALT:83 02SATM: 93.5 K: 3.6 K.M. 31-year old female Reason for admission: Anxiety, pain and difficulty breathing. Key Problem/ND #2 Ineffective breathing pattern related to decreased lung expansion as evidenced by lack of energy and fatigue Key Problem/ND # 1 Acute pain related to manipulation of tissues as evidenced by reports of pain Medical Diagnosis/Surgical Procedure: Arrythmia Diabetes mellitus (HCC) GESTATIONAL Post-partum depression Thyroid cancer Key Problem/ND #6 Risk for activity intolerance related to decreased oxygenation Key Problem/ND #5 Ineffective coping related to anxiety and panic attack. As evidenced by verbalization of being nervous before surgery Key Problem/ND #4 Decreased cardiac output related to decreased circulation in the heart. Key Problem/ND #3 Risk for unstable blood glucose level related to sedentary activity level as evidenced by staying in bed all day. Key Assessments Respiratory: crackles bilateral Abdomen: normal bowel sound, no pain. Heart sounds: S1, s2 present with turbulence on s1 Skin: dry and red spots Head and neck : normocephalic, no trauma or scars. Neurological: responsive and alert to verbal stimulus LOC: A&O to person, place and time MEDICATIONS Ketorolac (TORADOL) Injection 15mg (15mg IV. Lorazepam ( ATIVAN) injection mg (1mg IV PUSH). Xanax 0.25mg. Nadolol 10mg orally daily. Digoxin 0.25mg tab PO every 6hrs PRN.CONCEPT MAP 3 Problem # 1 and Nursing Diagnosis: Acute pain related to manipulation of tissues as evidenced by reports of pain General Goal: patient will verbalize the relief and control of pain Expected Outcome: Patient will exhibit the use of relaxation skills and activities most suitable for the situation Nursing Interventions: 1. Patient will be assessed for verbal and non – verbal reports of pain, indi cating location and duration. 2. P atient is posi tioned in a semi – fowlers position and give assistance to the head and neck with small pillows 3. C all light is kept within reach of patient. 4. P atient i s given c o l d liquids or soft foods, such as ice cream or ice blo c k s . 5. Patient is e ncouraged to use t herapeutic skill s like slow mus i c and guided reminisce . Rationale: 1. En sure that the evaluation is correct , choice s made on interventions and the succession of ther a p y after co m pletion are accurate. 2. This would avoid hyperextension of the neck and protects the tissue . 3. This would prevent the patient from stretching and straining the muscles. 4. Liquids can be accep ted more than solid foods if the patient has difficulty swallowing . 5. R educe d p ain and discomfort will foster rest. A re Evaluation : Patient verbalizes relief of pain and discomfort. States the pain is a 2 on a scale of “1 – 10” Goal met.CONCEPT MAP 4 Problem # 2 and Nursing Diagnosis: Ineffective breathing pattern related to decreased lung expansion as evidenced by lack of energy and fatigue . General Goal: P atient’s breathing remains within normal limits by end of the shift. Expected Outcome: Patient will maintain effective breathing pattern as evidenced by relaxed and normal breathing at an accepted rate with zero signs of dyspnea exacerbations while in the hospital and after the discharge. Nursing Interventions: 1. Administer respiratory medications and oxygen, as in the doctor’s orders . 2. Patient would maintain a semi – fowler position which would help increase the breathing pattern. 3. Patient is e d ucated on the side effects, dose and frequency of the medications. 4. C onsole and calm patient down during severity to prevent anxiety. 5. Patient is assisted with some AD L’ s, as needed or when necessary . Rationale: 1. Medications works on the relax ation of the breathing , causing the muscles to dilate and free flow of air . (Paap, Herzog, etal,2016). 2. Semi – fowlers position would help a voi d fluid back up into the lungs which aid s and increase breathing problems. (Wayne, 2019). 3. E ducatin g the patient about their medications, allows them administer medication as needed in a safe way . (Wayne, 2016). 4. The presence of a healthcare provider would help the patient feel less anxious, and secure . (Wayne, 2016). 5. This would save energy and assist in avoiding overexertion and fatigue.CONCEPT MAP 5 Evaluation: After oxygen treatment patient s breathing improved . Goal met . Problem # 3 and Nursing Diagnosis: Risk for unstable blood glucose level related to sedentary activity level as evidenced by . General Goal: Patient will maintain a blood glucose within the therapeutic range. Expected Outcome: Patient will grasp the need to keep sugar levels within the therapeutic range by keeping away from foods that will increase s ugar level and also ap propr iately take medications . Nursing Interventions: 1. Assess for signs of hyperglycemia and hypoglycemia 2. Make sure patient is respon ding to medications for decrease in blood sugar, patient is on insulin before and after every meal. 3. Help patient to work out eating habit s that needs to be stopped or worked on , patient was suggested to limit the intake of carbohydrates and eat more fruits and vegetables. 4. M ap out goals with patient on how important weight loss is, maintenance of appropr iate sugar levels and dail y exercises . 5. E du cate patient on how to administer and prepare medications in a safe and correct manner . Rationale: 1. Excess sugar in the blood can produce an osmotic effect that might result i n increase d thirst , hunger and urge to urinat e . (Gulanick, Myers 2014, p13). 2. Insulin covers patien t ’ s partial production of insulin and it gives the patient coverage and pre vents DKA. (Gulanick, Myers 2014, p1 4 ). 3. This will enlighten the patient more on what foods to avoid or reduce. (Gulanick, Myers 2014, p15). 4. Physical therapies of 30min few days in a week would be helpful. (Gulanick, Myers 2014, p13).CONCEPT MAP 6 5. Nurses can correct mistakes during administration, so the patient can do it correctly themselves . (Gulanick, Myers 2014, p15) Evaluation: Patients maintains blood glucose levels within normal range . Problem # 4 and Nursing Diagnosis: D ecreased cardiac output related to decreased circulation in the heart . General Goal: Maintain blood pressure within the normal range Expected Outcome: Patient would demonstrate adequate cardiac output as evidenced by blood pressure and pulse rhythm within normal range.CONCEPT MAP 7 Nursing Interventions: 1. Mon i toring patients intake and output 2. Monitoring patients blood pressure every 3 – 5 hours 3. Administering oxygen to the patient 4. Making sure patient is always sitting in a semi – fowler 5. S ugg est to patient on ho w to apply music therapy to help reduce anxiety to boost cardiac function. Rationale: 1. This would supply data for contrasting and evaluat ing results of intervention . (Gil, Wayne 2016). 2. To gain data and foster improvement on the interventions that are provided . (Gil, Wayne 2016). 3. M ak e oxygen available t o the tissu es (Gil, Wayne 2016). 4. This would assist in the reducti on of oxygen intake and risk for decomposition (Gil, Wayne 2016). 5. Music b een proven to a cce lerate recovery and has aided in reduction of heart rate , blood pressure and anxi ousness . (Gil, Wayne 2016). Evaluation: After 8 hours of providing care, the patient did not experience any further complications for decreased cardiac output as evidenced by a normal blood pressure which is 118/ 80. Reference Gulanick, M., L.J. (2014). Nursing Care Plans: Diagnosi s, interventions, and o utcome . St. Lois, MO; Elsevier, Inc. Paap, M. C. S., Lenferink, L. I. M., Herzog, N., Kroeze, K. A., & Van der Palen, J. (2016). The COPD -CONCEPT MAP 8 SIB: a newly developed disease – specific item bank to measure health – related quality of life in patients with chronic obstructive pulmonary disease. Health & quality of life outcomes , 14, 1 – 5. https://ezproxy.felician.edu:2444/10.1186/s12955 – 016 – 0500 – 0 Wayne, G. (2019). Ineffective breathing pattern. Retrieved from https://nurseslabs.com/inneffective – breathing – patt ern Wayne, G. (2019). Acute pain. Retri e ved from https://nurseslabs.com/acute – pain/%3famp

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