RUA Concept Map
Running Head: Concept Map 1
Patient Care Plan and Concept Map
Esther Ogueri
NR 226: Fundamental – Patient Care
Professor: Mai Nguyen
June 06, 2021
Concept Map 2
Individual’s Information
Patient J.L. is a 90-year-old Caucasian female that resides at a skilled nursing facility. The patient was admitted to the facility in December of 2016. The patient has ordered as a “DNR,” meaning the patient does not wish to be resuscitated via CPR. The patient is widowed, and her next of kin/power of attorney is her son. Patient J.L. is retired but was formerly a secretary. She was admitted to the facility for hypertension, age-related osteoporosis, and a history of falls. She is also diagnosed with osteoarthritis, generalized muscle weakness, difficulty walking, major depressive disorder, hyperlipidemia, dehydration, pulmonary embolism, vascular implants and grafts, cognitive-communication deficit, and a cyst of the kidney.
According to Gould’s Pathophysiology for Health Professions (2014) by Karin C. VanMeter and Robert J. Hubert, osteoporosis is the loss of bone density due to the loss of calcium salts (VanMeter, Hubert, 159). This disorder primarily affects women when postmenopausal due to estrogen deficiency (VanMeter, Hubert, 169). Osteoporosis tends to affect bones with more cancellous bones, such as the bones that make up the vertebrae and femoral neck (VanMeter, Hubert, 169). Other predispositions for the condition include immobilization, increased age, calcium and vitamin D deficits, hormonal factors, cigarette smoking, small light bone structure (Caucasians and Asians), and more (VanMeter, Hubert, 169). Being a woman, Caucasian, elderly, and having a sedentary lifestyle, the patient had a high disposition to the condition. The patient is being treated for the situation with Vitamin D supplements daily.
Concept Map 3
Essential hypertension, another significant diagnosis, is high blood pressure. According to Gould’s Pathophysiology for Health Professions (2014) by Karin C. VanMeter and Robert J. Hubert, women postmenopausal are more likely to suffer. (VanMeter, Hubert, 258). The cause is
idiopathic and is diagnosed when blood pressure consistently is measured above 140/90 mmHg. (VanMeter, Hubert, 259). In hypertension, the patient has an increase in arteriolar vasoconstriction, which several stimuli may cause. The incidence of the disease increases with age and familial trends, high sodium intake, excessive alcohol intake, obesity, and prolonged or recurrent stress (VanMeter, Hubert, 260). The patient treats her hypertension with a few different medications.
Assessment
The patient was in bed in a semi-fowler position. Alert and oriented x3/3. GCS 15/15 (4) (5)(6). Motor and sensory functions grossly intact. Appropriate mood and affect for the situation. Behavior was appropriate for the situation. The patient presented normal posture. The patient presented appropriate nutrition, some abdominal obesity.
Skin pink, warm, dry. Elastic turgor present. No tenting. The hair was fine and white. Capillary refill was less than three seconds. No clubbing of nails present. The patient head and scalp were normocephalic, and no lesions or infestations present to palpation. The patient facial structures were symmetric, and the patient demonstrated the ability to smile, raise eyebrows, and frown. CN VII is intact.
Pupils were equal, round, reactive to light with accommodation. The patient demonstrated the ability to follow six cardinal gazes. The patient wears glasses for good visual acuity. CN II, III, IV, and VI intact. The patient demonstrated hearing acuity intact with the
Concept Map 4
ability to maintain a normal conversation. No skin breakdown behind ears. CN VIII is intact. The patient nose appeared symmetrical on the face, with no drainage or foreign bodies. The septum
has slightly deviated to the right. Nasal patency was intact. The patient vocalized no abnormality with a sense of smell. CN I is intact. Lips were slightly dry. Oral mucosa was pink and moist. The patient wears a full set of dentures. The tongue was midline, uvula midline. The patient demonstrated the ability to say “ahhh” and swallow. CN IX, X, XII intact. The speech was normal, and the patient vocalized
without difficulty. Patient able to clench jaw. Cranial Nerve V intact.
Trachea midline. Thyroid palpated, no goiter or lesions present. Loose skin due to aging. Patient able to shrug shoulders. CN XI is intact. Lung field clears bilaterally to auscultation anteriorly and posteriorly; no adventitious sounds noted. Apical pulse rate and rhythm regular. Normal S1 and S2 present to auscultation in five cardiac areas. Carotid, radial, and pedal pulses palpable and equal bilaterally, 2+. Active bowel sounds present in all quadrants. The abdomen was soft, non-tender. Last Bowel Movement this afternoon, small, soft, semi-formed.
The upper extremities demonstrated equal strength bilaterally. Unlimited ROM in wrist, elbows, and shoulders. Shown from ADLs (dressing). No tenderness, swelling, or joint deformities noted. Fingers presented ulnar deviation. Denied tingling and numbness in extremities. No peripheral edema was noted in the upper extremities.
Lower extremities demonstrated bilateral muscle weakness. The patient is unable to ambulate without assistance, uses caretakers in moving from bed to wheelchair. The patient uses a sliding board for help as well. Patient able to point and flex toes very weakly. Patient unable to
Concept Map 5
bend knee joint or hip joints actively. Passive ROM demonstrated limited ROM in hip joints. Passive ROM showed full ROM in knee joints. Muscle strength does not present in lower extremities. No tenderness, swelling, or joint pain in the lower extremities. The patient denied tingling and numbness. Lower right leg, posterior calf, positive for cellulitis. Slightly pink in area, and slight edema noted. Skin in the upper leg and other leg appears to have typical pink, warm, and dry consistency—loose skin present related to aging.
Reflection: Communication
Between the client and I, I demonstrated the use of therapeutic communication. I avoided interviewing and client communication traps, such as using “why” statements, using leading
questions, giving unwanted advice, and using professional jargon. I made it a point to make eye contact with my client and actively listen when my client was speaking. I did my best to control my nonverbal skills, such as maintaining my posture and using proper gestures. I tried to make the environment for my client as comfortable as possible to allow my client to feel as safe as possible while talking with me. I also used therapeutic touch with my patient by putting my hand on her soldier at one point. In time, goals that have not yet been met will be evaluated. At the current time, goals are progressing to meet the desired outcome. Work to maintain these desired outcomes is always a goal.
Reflection: Safety
During my clinical, I did my best to utilize all safety precautions I could. For example, I made sure the client’s bed is a lower position if I turned my back on the client to reduce the fall risk. I also made sure that the wheelchair locked is during transfer. I made sure I used the safety rails of the bed when my patient was in her bed. Each time I entered and exited the client’s room,
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I performed hand hygiene in infection control. Before touching the patient, I performed hand hygiene again, and I used proper personal protective equipment (gloves) when providing perineal care and changing my patient’s diaper. I discarded the gloves in the proper receptacle after use. After providing care, I also performed hand hygiene again.
Concept Map 7
References:
Carpentino, L. J. (2017). Handbook of Nursing Diagnosis (15th ed.). Philadelphia, Pennsylvania: J.B. Lippincott Company. VanMeter, K. C., & Hubert, R. J. (2014). Gould's Pathophysiology for Health Professions (5th ed.). St. Louis, MO: Elsevier Saunders. Kilic, S. (2017). Is Activity Intolerance One of The Nursing Diagnosis for Patients with Depression? Journal of Psychiatric Nursing,8(2), 127-128. Retrieved June 6, 2021.