Care Map

 

Explain how the data clusters helped you to determine the Gordon’s Functional and Dysfunctional Patterns.

The data clusters helped split everything into categories and organize the data. When splitting them into Gordon’s patterns, 5 patterns contained data that was considered dysfunctional; Health Perception/Health management, Coping/Stress Tolerance, Nutritional-Metabolic, Activity-Exercise and Elimination

2. Using Gordon’s as a guide, which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).

Health Perception/Health Management:

Knowledge deficient RT uncontrolled diabetes as evidence by not knowing how to inject insulin, not exercising and not know how coffee effects blood sugar

Ineffective Health maintenance RT complexity of therapeutic regimen as evidence by multiple complex chronic diseases

Coping/Stress Tolerance:

Risk for Hopelessness RT new medication as evidence by wanting to stay in hospital to start new drug

Risk for situational low self-esteem RT physical illness as evidence by not having confidence in new medication, not being able to inject insulin and not knowing about diet control

Nutritional-Metabolic:

Risk for impaired skin integrity RT uncontrolled diabetes as evidence by patient having to check feet, Hb A1C 8.9 and elevated blood glucose levels

Impaired skin integrity RT cardiac procedure as evidence by post cardiac catheterization

Risk for bleeding RT s/p cardiac procedure as evidence by post cardiac catheterization access through right radial artery

Risk for Unstable Blood Glucose RT inadequate blood glucose monitoring as evidence by out of normal range BG, Hb A1C 8.9, and not proper diet choices

Elimination:

Impaired Urinary elimination RT yeast infection as evidence by dysuria, and elevated white blood cell count

Activity-Exercise:

Impaired Gas Exchange RT abnormal breathing pattern as evidence by SOB and not being able to take deep breaths

Risk for Decreased Cardiac output RT altered contractility as evidence by hypertension, heart failure and stress test results

List the identified nursing diagnoses in the:

Impaired Gas Exchange RT abnormal breathing pattern as evidence by SOB and not being able to take deep breaths

Risk for situational low self-esteem RT physical illness as evidence by not having confidence in new medication, not being able to inject insulin and not knowing about diet control

Knowledge deficient RT uncontrolled diabetes as evidence by not knowing how to inject insulin, not exercising and not know how coffee effects blood sugar

Which nursing diagnosis is most important to address with this client? Explain how this was determined.

Impaired Gas Exchange RT abnormal breathing pattern as evidence by SOB and not being able to take deep breaths. This was determined because if there is an impaired gas exchange, oxygen and other nutrients can not get to the whole body.

Which nursing diagnosis is second most important to address with this client? Explain how this was determined.

Knowledge deficient RT uncontrolled diabetes as evidence by not knowing how to inject insulin, not exercising and not know how coffee effects blood sugar. This was determined as the second most important because the patient has uncontrolled diabetes which can lead to a great number of other issues.

Which nursing diagnosis is least important to address with this client? Explain how this was determined.

Risk for situational low self-esteem RT physical illness as evidence by not having confidence in new medication, not being able to inject insulin and not knowing about diet control. This was chosen as the least important because this will resolve as the patient gets better control over her diabetes