Nursing
Concept map template
Assessment
Subjective /objective data
Mrs T.S is a 69- year -old female diagnosed with Vestibular Schwannoma, on the right side of the head, she is alert and oriented to person, place and situation. Her vital signs are BP 120/72, Temp 38.9, heart rate 133beats/min, respi 20beats/min, oxygen 96% on high flow of 30Lit/mins with FiO2 of 50% and map 88, pain was unable to rate her pain level as she was unable to talk. Upon auscultation of the heart sounds, S1S2 heard with no heart murmurs, capillary refill was <3sec. Patient was cooperative, no edema on both upper and lower extremities.
Body Systems
HEENT: Normocephalic with surgical suture on the right side, ears are symmetrical to face, no drainage, no lesion, tenderness on the right ear and deafness, eyes are symmetrical to face, pupil are equal, round, reactive to light and accommodative. Nose is symmetric, mucosa is pink, no drainage or redness. Mouth is moist, lips pink, mucosa pink, all teeth present. Trachea midline, thyroid palpable, no swelling noted.
Neuro: Patient is alert X2 to person and place, is non-verbal but follows directions and cooperates, has facial drooping on the left side. PERRLA is 3mm.
CV: BP 120/72, HR 133, MAP 88, . Upon auscultation of the heart sounds, S1S2 heard with no heart murmurs, capillary refill was <3sec. Pulse +2 bilaterally in radial, dorsalis pedis.
RESP: RR 20beats/min, Spo2 96% on high flow oxygen at 30L/min with FiO2 at 50%. During auscultation the respiratory sounds are clear on all lung lobe. No use of accessory muscle observed.
Musculoskeletal: Patient has full ROM and muscle strength bilaterally on both upper extremities, full muscle strength on the left leg and limited muscle strength and ROM on the right leg.
GI: Patient is NPO diet, input of 210ml and output of 350ml. Hyperactive bowel sounds hard on all four quadrants upon auscultation, no distension noted.
GU: External urinary catheter, monitor I/O 350ml urine output, urine is yellow and clear.
Skin: 20G IV on left forearm no signs of infiltration, DVT on right leg, wound on sacrum covered with dressing, no edema.
Reproduction: Patient lives alone, no current significant other.
Patient
Name: T.S
Fall Risk
Age: 69 years old
Code status: Full code
Precaution: Fall
Allergies: No known allergies
Language: English
Marital status: Single
Employment: Retired .
Past Medical History:
Hypertension, recent covid 19 infection, hyperlipidemia, COPD, Gastroesophageal reflux disease, ear deafness on the right ear.
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pathophysiology :
A vestibular schwannoma (also known as acoustic neuroma, acoustic neurinoma, or acoustic neurilemoma) is a benign, usually slow-growing tumor that develops from the balance and hearing nerves supplying the inner ear. The tumor comes from an overproduction of Schwann cells which normally wrap around nerve fibers like onion skin to help support and insulate nerves. As the vestibular schwannoma grows, it affects the hearing and balance nerves, usually causing unilateral (one-sided) or asymmetric hearing loss, tinnitus (ringing in the ear), and dizziness/loss of balance. As the tumor grows, it can interfere with the face sensation nerve (the trigeminal nerve), causing facial numbness. Vestibular schwannomas can also affect the facial nerve causing facial weakness or paralysis on the side of the tumor. If the tumor becomes large, it will eventually press against nearby brain structures (such as the brainstem and the cerebellum), becoming life-threatening (Medline Plus, 2020). Early detection of the tumor is sometimes difficult because the symptoms may be subtle and may not appear in the beginning stages of growth. Once the symptoms appear, a thorough ear examination and hearing and balance testing like audiogram, electronystagmography, auditory brainstem responses are essential for proper diagnosis. Magnetic resonance imaging (MRI) scans are critical in the early detection of a vestibular schwannoma and are helpful in determining the location and size of the tumor and in planning its microsurgical removal (Medline Plus, 2020). Early diagnosis of a vestibular schwannoma is key to preventing serious consequences and there are three options for managing a vestibular schwannoma: surgical removal, radiation, and observation. The type of treatment done depends on the size of the tumor and the level of hearing in the affected ear. As the tumor grows larger, surgical removal is more complicated because the tumor may have damaged the nerves that control facial movement, hearing, and balance and may also have affected other nerves and structures of the brain (Medline Plus, 2020). Radiation therapy is sometimes the preferred option for elderly patients, patients in poor medical health (Medline Plus, 2020).
Gordon Pattern and cluster data
Patient bowel sounds are present on all four quadrants she did not have a bowel movement throughout the shift and uses urinary catheter as she is on bed rest.
Patient is incontinent
Relevant Gordon Pattern: Elimination
Definition: “Ability to excrete waste products.” (Doenges & Moorhouse, 2013,p.17).
Functional
NDX: Bowel and urine incontinence related to health complications .
Gordon Pattern and cluster data
Patient is 69 years old with weak muscle strength and unable to self ambulate or reposition herself in bed. Total dependent for ADL’s
Patient cannot perform full range of motion exercise on lower extremities. Right lower leg is a little stiff due to inactivity and DVT.
Relevant Gordon Pattern: Activity/Exercise
Definition: “Ability to engage in necessary/desired activities of life (work and leisure) and to obtain adequate sleep/rest”. (Doenges & Moorhouse, 2013,p.17).
Dysfunctional.
NDX: Activity intolerance related to health complications as evidence by patient not being able to tolerate range of motion exercise on right lower extremity.
Gordon Pattern and cluster data
Patient is on an NPO diet and on IV fluids to help with electrolyte balance due to NPO diet.
Relevant Gordon Pattern: Nutrition/Metabolic
Definition: “Patterns of food and fluid intake, fluid and electrolyte balance, general ability to heal”. (Doenges & Moorhouse, 2013,p.17).
Dysfunctional
NDX: : Nutritional imbalance, related to insufficient food intake and depending only on fluids for electrolyte balance.
Gordon Pattern and cluster data
Patient is single, has two children a daughter and a son who are her support system and lives alone as read in the notes.
Relevant Gordon Pattern:
Role/Relationship
Definition: “Client’s perception of major roles and responsibilities in current life situations”. (Doenges & Moorhouse, 2013,p.17).
Functional
NDX: Patient has a good support system from her children.
Gordon Pattern and cluster data
Patient perceives self as being a burden to her children and care giver as she is fully dependent and can not carry out her ADLs without help.
Relevant Gordon Pattern:
Self-Perception/Self-Concept
Definition: “individual’s attitudes about self, perception of abilities, body image, identity, general sense of worth, and emotional patterns.” (Doenges & Moorhouse, 2013,p.17).
Dysfunctional
NDX: Powerlessness related to patient being fully dependent on others for ADL’s as evidence by not feeling comfortable when she is being cleaned up.
X-Rays
Chest X-ray for Nasogastric tube placement:
Nasogastric rube follows the expected course of chest to region of gastric antrum. There is patchy opacity at the left lung base which may be combination of small pleural effusion, atelectasis, infiltrate.
No evidence of pneumothorax, the cardio mediastinal silhouette is stable and no acute osseous abnormalities detected.
Images
MRI: MRI of the brain showed a 4.6 x 4.3 x 3cm on the right cerebellopontine angle tumor associated with edema and displacement of the 4th ventricle without obstructive hydrocephalus.
CT Scan of head with noncontrast
The ventricular system is mildly prominent, mildly diminished in size since prior imaging particularly. The third ventricle is smaller in diameter and the compressed fourth ventricle is now identified.
There is a large area of heterogeneous density and mass effect in the right cerebral pontine angle which does not appear to be significant.
The mastoid air cell and paranasal sinuses are within normal limits and the calvarium is uremarkable.
List doctors order
High flow NC (RT)
Chest physiotherapy/ bronchial hygiene every 4hours due to copious sputum production.
Continuous pulse oximetry to monitor oxygen saturation
Nasotracheal suctioning every 4 hours to prevent aspiration from secretions
Telemetry monitoring for class two electrolyte imbalance continuously
Cenedella bed daily because patient has deep tissue injury, stage 3 wound.
| LABS | RESULTS | HIGH/LOW | REASON FOR ABNORMALITY |
| WBC | 16.1 | high | `This might indicate a sign of infection. |
| RBC | 3.64 | low | This is might indicate anemia as a result of blood loss due to surgery. |
| Hemoglobin | 9.8 | low | Indicate dehydration as patient is tachycardiac. |
| Hematocrit | 30.5 | low | This is low because enough red blood cells are not produced. |
| Platelets | 255 | normal | n/a |
| CO2 | 36 | high | Due to the patient’s COPD condition as there is increase CO2 in blood stream |
| BUN | 44 | high | Is high because the body is breaking down protein and the body don’t have enough protein. |
Labs
| LABS | RESULRTS | HIGH/LOW | REASON FOR ABNORMALITY |
| Potassium | 3.6 | normal | n/a |
| Creatinine | 0.34 | low | This might be due to low muscle mass and indicate kidney disease. |
| Sodium | 150 | high | This indicates dehydration |
| Glucose | 179 | high | This might be coursed by stress and pain. |
Labs
| Medication | Class | Dose/Route/Frequency | Indication | Top 3 side Effects |
| Cefazolin injection. | Antibiotic | 2g, intravenous, every 8 hours | Used to treat bacterial infection | Confusion, oral candidiasis, loss appetite. |
| Enoxaparin (Lovenox) | Anticoagulant | 40mg, subcutaneous, daily | Use to treat and prevent deep vein thrombosis and pulmonary embolism. | Nausea, peripheral edema, bleeding. |
| Famotidine tablet | Antiulcer | 20mg, by mouth, twice daily | Inhibits histamine action of H2 receptors of parietal cells. | Confusion, constipation, thrombocytopenia |
| Insulin regular injection | Antidiabetic | 0-8units, subcutaneous, every 6hours | Use to treat type 1 diabetes and type 2 to improve glycemic control | Hypoglycemia, angioedema, lipohypertrophy |
| Magnesium hydroxide | Laxative | 30ml, by mouth, every night | Acts in stomach to neutralize gastric acid and short-term treatment of constipation | Chalky taste, palpitations, hypermagnesemia. |
| Hypromellose 0.5%( Artificial tears) | Eye drop | 5% ophthalmic solution, 2drops in right eye, every 2hours | Use to | Blurred vision, burning sensation, irritation. |
Medications
Educational nsg Dx
Knowledge deficit related to new diagnosis of respiratory failure as evident by patient not able to understand the prognosis.
Goal/outcome
Educate and provide adequate information and referrers to patient and care giver on how to manage patients condition by the end of discharge.
Intervention and rational
Teach patient about importance of adequate nutrition to enhance healthy lifestyle and healing process. R/ Malnutrition may reduce respiratory mass and strength affecting muscle functioning (Gulanick,2017).
Educate patient and care giver to adjust home environment as necessary. R/ Installing air filters to decrease irritants in environment decreases patient’s effectiveness in assessing oxygen during breathing(Gulanick,2017).
Teach patient and care giver the importance of elevating head of the bed at 45degree or as tolerated . R/ Elevating the head of the bed and sitting in an upright position allows increase thoracic capacity which expands the lungs and enhance breathing (University of California San Francisco, 2022).
Educate patient and care giver on the importance of regular follow up appointment. R/ Keeping up with regular follow up appointments is important to avoid reoccurrence of crisis.
Evaluation
Goals not met
Patient was still in hospital, under observation and getting treatment. Evaluation will be done by discharge.
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Physiological Nsg Dx
Ineffective breathing pattern related to history of COPD as evident by patient use of assessor muscles in breathing.
Goal/outcome
Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at normal rate and depth and absence of dyspnea.
Patient’s respiratory rate remains within established limits.
Patient’s ABG levels return to and remain within established limits.
Intervention and rational
Assess and record respiratory rate and depth at least every 4 hours. R/ The average rate of respiration for adults is 10 to 20 breaths per minute. It is important to take action when there is an alteration in breathing patterns to detect early signs of compromise on the respiratory system (Gulanick,2017).
Observe breathing patterns. R/ Unusual breathing patterns may imply an underlying disease process or dysfunction. Cheyne-Stokes respiration signifies bilateral dysfunction in the deep cerebral or diencephalon related to brain injury or metabolic abnormalities. Apneusis and ataxic breathing are related to the failure of the respiratory centers in the pons and medulla (Gulanick,2017).
Assess ABG levels according to facility policy. R/ This monitors oxygenation and ventilation status (Gulanick,2017).
Auscultate breath sounds at least every 4 hours. R/ This is to detect decreased or adventitious breath sounds which may include Bronchospasm, Rales, Rhonchi, Wheeze (Gulanick,2017).
Evaluation
Goals were met as patient’s breaths were within normal limits, no signs of dyspnea.
Psychosoical Nsg Dx
Ineffective copping related to communication as evident by patient unable to make needs known.
Goal/outcome
Patient will be able to communicate needs by writing on a board by the end of the shift.
Patient will be able to verbalize her needs by the end of discharge.
Intervention and rational
Provide a white board for patient to write her needs and concerns. R/ Providing a board and marker for patient to express her concerns and needs enhances communication between the nurse and the patient which leads to quality care. (University of California San Francisco, 2022).
Encourage patient to recognize her strengths and abilities. R/ Patient may not be able to recognize her strength and abilities during health crisis by fostering awareness can expedite use of strength thereby gradually enhancing healing process (Gulanick,2017).
(Use empathic communication when communicating with patient. R/ Acknowledging and empathizing when communicating with patient creates a supportive environment that enhances copping.
Provide chance for patient to express concerns, fears, feelings and expectations. R/ Expressing concerns, fears and feelings helps reduce anxiety and opens a chance for communication between patient and staff (Gulanick,2017).
Evaluation
Goal was not met. Patient was unable to write on a board due to weakness, fatigue. Evaluation of goals will be assessed before discharge.
Write about what you just did and how you thought about it. Each Gordon’s Patterns set shall be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume I know anything about your thought process, because I don’t. Show me how you are thinking! How to begin…………….
Include ALL of the questions with the Answers of the questions:
In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped you.)
Using Gordon’s as a guide, which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).
List the identified nursing diagnoses in the:
“Problem” Related to “_____ “ Evidenced by “____” format.
Which nursing diagnosis is most important to address with this client? Explain how this was determined.
Which nursing diagnosis is second most important to address with this client? Explain how this was determined.
Which nursing diagnosis is least important to address with this client? Explain how this was determined.
Answer questions
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Select the priority physiological and psychosocial (NSG240) and educational (NSG245 and NSG430) Nursing diagnoses. Complete the Nursing process by answering the questions below and including the information in the explanation paper for each priority nursing diagnosis:
What is the goal for the client to show that the priority problem is reduced or resolved?
What would a nurse (you) need to do for the client to help the client meet the goal?
How would you know that the client has met the goal?
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Reference
Gulanick, M., and Myers, J,L, (2017) nursing care plans: diagnoses interventions, and outcomes.
Jacobi, J. (2018). Pathophysiology of sepsis. American Journal of Health-System Pharmacy : AJHP : Official Journal of the American Society of Health-System Pharmacists, 59 Suppl 1(1), S3-8. https://doi.org/10.1093/ajhp/59.suppl_1.S3.
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.
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