MD4

Nursing Concept Map

The Nursing Concept Map MUST include:

· The clients primary and medical diagnoses (-3 points for every missing medical diagnosis)

· List of medication, dose, and frequency for each medical diagnosis (-3 for missing medications)

· Priority Nursing Diagnoses that convey your patient’s situation (-5 points for missing nursing diagnosis; -3 for missing/incomplete/or incorrect format)

· Nursing Diagnoses should be written in full format with a related to (r/t) and with correlating subjective and objective assessments.

· Student cannot use Risk for Nursing Diagnoses, unless instructed

· Each Nursing Diagnosis needs 3 interventions that you did with and/or for the patient. (- 5 points if missing a nursing diagnosis or rationale; - 3 points if the intervention is not patient specific)

· Interventions must be patient specific

· i.e The nurse administered Tylenol 650 mg PO for mild to moderate pain.

· Every intervention needs a rationale from a Nursing Diagnosis Textbook

· i.e The nurse administered Tylenol 650 mg PO PRN for mild to moderate pain. Rationale: Nonopioids such as Tylenol are first-line analgesics for the treatment of mild acute pain

·

Acute pain r/t physical or biological agents AEB pt report occasional knee pain 3/10, swelling and has difficult with ambulation.

· Multivitamin 1 tab Daily

· Enlive Juice 40oz PO Daily

· Calcium Carbonate 500 mg TID

zSD

· Administer furosemide 40mg PO daily and monitor I/O. Rationale: Monitoring I/O is useful for monitoring effects of diuretic therapy.

· Nurse applied TED hose after shower and elevated feet with patient was sitting in the chair. Rationale: Treatment for peripheral edema include the use of sequential compression devices and elevation of extremities.

· Nurse maintained the HOB 45 degrees while patient was lying in bed during the 0700 – 1400 shift. Rationale: Increased intravascular volume results edema and JVD.

Excess fluid volume r/t compromised regulatory mechanism AEB +1 edema to left and right ankles

· The nurse used empathy and answered all questions with repetition. Rational: The way the nurse interacts with a client influences their quality of life.

· The nurse used therapeutic touch when client expressed, they wanted to go home. Rational: Therapeutic touch can reduce anxiety.

· The nurse will administer clients scheduled lorazepam 0.5 mg every 6 hours. Rationale: The use of anti-anxiety meds is effective for anxiety.

Anxiety r/t alteration in attention and forgetfulness AEB patient oriented to person only and forgetful when previously performed nursing cares have been done.

· Memantine (Namenda) 10 mg PO BID

· Administer Tylenol 650 mg PO PRN for mild to moderate pain. Rationale: Nonopioids such as Tylenol are first-line analgesics for the treatment of mild acute pain

· Assisted the client with ROM exercises. Rationale: Nonpharmacological methods can be used to complement pharmacological treatment for pain

· Nurse applied warm packs to knees at 0900 and again at 1400. Rationale: Teaching about non-pharmacological interventions can restore client sense of self-control

M.l

82y/F

· Wellbutrin 300mg PO Daily

· Trazadone 75mg PO HS

Depression

· No c/o feeling of despair or sadness

· No loss of interest in activities such as quilting

· No change in weight – current weight 145lbs; last month weight was 142lbs.

· Nurse provided verbal education with every medication administered to client. Rational: Education supports control of symptoms and medication adherence.

· Nurse encouraged patient’s daughter to review medications with nursing home staff and client after every hospitalization and clinic visit. Rationale: Patient-centered care requires a supportive relationship between the client and healthcare professionals.

· Nurse validated feelings about medications by having the client read each medication label and had client open her own medication after scanning. Rationale: Self-care is correlated with concepts of health literacy and self-efficacy.

Hypertension

· BP 160/56 on left arm

· No irregular HR – HR reg 76

· Patient denies headache

· Lipitor 10 mg PO Daily (for cholesterol – risk factor for HTN

· Carvedilol (Coreg) 3.125 mg PO Daily

· Ramipril 5 mg PO Daily

Osteoarthritis

· Patient reports that both knees swell sometimes

· Pt reports occasional knee joint pain (3/10)

· Patient has difficult walking at times and needs a cane

Key: Green = Medical Diagnosis; Orange = Meds; Blue = Nursing Diagnosis; Purple = Nursing interventions and Rationale

Ineffective Health Management r/t insufficient knowledge of therapeutic regimen AEB at home medications are given per nursing home staff and patient is only alert to person.

· Protonix 40 mg PO Daily

GERD

· Patient did not c/o heartburn or chest pressure

· Patient does not have difficulty swallowing food

· Patient denies any regurgitation of food after eating

· Furosemide (Lasix) 40 mg PO Daily

CHF

· No c/o SOB

· No JVD.

· Patient has +1 edema to left and right ankles

Alzheimer’s Disease

· Alert to person only, unable to state place or date.

· Patient forgetful with tasks

· Patient needs assistance with ADLs