Nursing
happiness2000
NSG110Classconceptmaptemplate2.pptConcept map template
Nursing 110
Name: Sekinot Mohammed
Class: NSG 110
Due Date:11/16/2021
Patient’s Initials:M.K
Step 1: Complete the chart using the patient assigned to you. You may want to refer to the Physical Assessment Chapter in the Tres & Wilkinson text for assistance. Do not leave any box blank, use “Not Applicable” if there is absolutely nothing that you can identify for the box.
| Body Systems | Subjective Data | Objective Data |
| Neurologic | Not applicable | Alert and oriented to situation, responsive to question, eye contact. |
| HEENT (Head, Eyes, Ears, Nose, Throat) | Not applicable | Verbalize appropriately, makes eye contact with nurse. No apparent hearing deficit. |
| Integument | Not applicable | Warm and dry. Redness on buttocks and sacral area. |
| Musculoskeletal | Not applicable | Unable to move on her own, ambulate, dependent with all ADL’S |
| Cardiovascular | Not applicable | Hx of heart failure, B/P 98/54, HR 86 regular |
| Respiratory | Not applicable | Respiratory 22 of unlabored |
| GI | “I lost a lot of weight. I don’t like the food at the nursing home”. | Lost a lot of weight. Does not eat her food at the nursing home. Incontinent of bowel |
| GU | Not applicable | Incontinent of urine |
| Emotional/Social/Spiritual | “I got very mad at God. How could He take my husband and leave me all alone? My husband used to take care of me”. | Appears to be sad and grieving |
| Reproductive | Not applicable | Not applicable |
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Step 2: Group the subjective and objective data that belong together in the same data cluster. Identify the correct Gordon’s Pattern. Note: Findings may repeat in multiple boxes this is the process of forming “data clusters”. Not every box will have data – type not applicable under the data cluster, but give a definition. Expand and rearrange the boxes as needed.
Clustered Data (all relevant)
Not applicable
Relevant Gordon Pattern: Health Perception/Health Management
Definition:
Clustered Data (all relevant)
Not applicable
Relevant Gordon Pattern:
Sleep/Rest
Definition: Patterns of sleep, rest, and relaxation
Clustered Data (all relevant)
Not applicable
Relevant Gordon Pattern: Sexuality/Reproductive
Definition: Patterns of satisfaction and dissatisfaction with sexuality patter, reproductive pattern.
Clustered Data (all relevant)
“I got very mad at God. How could He take my husband and leave me all alone? My husband used to take care of me”
Relevant Gordon Pattern: Value/Belief
Definition: Patterns of values, belief (including spiritual), and goals that guide client’s choices or decisions.
Clustered Data (all relevant)
Not applicable
Relevant Gordon Pattern: Cognitive/Perception
Definition: Sensory-perceptual and cognitive patterns.
Clustered Data (all relevant)
Incontinent of urine and bowel. Redness on buttocks and sacral area.
Relevant Gordon Pattern: Elimination
Definition: MRSA. Patterns of excretory function (bowel, bladder, and skin). “Includes Client’s perception of normal” function.
Clustered Data (all relevant)
“I lost a lot of weight. I don’t like the food at the nursing home”.
Relevant Gordon Pattern: Nutrition/Metabolic
Definition: Pattern of food and fluid consumption relative to metabolic need and patters; indicators of local nutrient supply. She will need 2 pounce by the next 30 days
Clustered Data (all relevant)
Unable to move on her own. Dependent on staff to move.
Relevant Gordon Pattern: Activity/Exercise
Definition: Patterns of exercise, activity, leisure, and recreation.
Clustered Data (all relevant)
“I got very mad at God. How could He take my husband and leave me all alone? My husband used to take care of me”
Relevant Gordon Pattern: Coping/Stress
Definition: General coping pattern and effective of the pattern in terms of stress tolerance.
Clustered Data (all relevant)
Not applicable
Relevant Gordon Pattern:
Self-Perception/Self-Concept
Definition: Client’s self-concept pattern and perceptions of self.
Clustered Data (all relevant)
“I got very mad at God. How could He take my husband and leave me all alone? My husband used to take care of me”.
Relevant Gordon Pattern:
Role/Relationship
Definition: Client pattern of role engagements and relaitonships.
Patient Name:M.K
Age:72
Gender: F
Chief Complaint: Chest pain and shortness of breath
Clustered Data (all relevant)
“I lost a lot of weight. I don’t like the food at the nursing home”.
Relevant Gordon Pattern (name, functional or dysfunctional): Nutrition metabolic dysfunctional
Associated Nursing diagnostic label: Nutrition less than body requirement related to decrease food intake aeb pt’s complaint of not liking food (Doenges, M. E. et al, 2019, p.582),
Patient Name: M.K.
Age: 72
Gender: Female
Situation: Patient is dysfunctional but stable
Priority Nursing Diagnostic Statement:
Pt nutrition is not sufficient due to less body requirement r/t unable to eat or not liking the food aeb weight loss. The pt is grieving due to the death of her husband aeb stating to be blaming God risk for social isolation. Self care Deficit r/t she need assistance to be able to ambulate aeb needed assistance also for her ADL’S. Risk for falls and impaired mobility, impaired skin integrity r/t the redness and sacral area.
Diagnostic Label: Pt has Spiritual Distress r/t being mad at God aeb feeling she has been abandoned by her husband and blaming God that her husband will not be able to take care of her anymore.
Goal:
Patient will resolve MRSA and will get back to nursing home
2-3 SMART outcomes:
1. Pt will have no s/s of UTI next 14 days
2. Pt will be free from skin breakdown within the next 30 days
3. Pt will consume 75-100% of all meals in the two weeks
4. Pt will sustain no falls for the next 14 days.
In your own words, based on the data cues, what is the most important (priority) problem?
Patient M.K. was admitted for congested heart failure and she will be sent back to nursing home and was discover after the lab test that showed MRSA in her urine. Pt appears to have nutrition and metabolic dysfunctional due to the fact she couldn’t eat well aeb weight loss, stress coping with grieving of loss of her husband’s death. Pt also has an elimination dysfunctional and impaired skin integrity as a result of redness on her buttocks and sacrum,
List and prioritize all Nursing Diagnostic Statements (3 part or 2 part) based on data clusters above (at least 3):
1. Infection r/t UTI aeb abnormal lab result with detection of MRSA
2. Impaired skin integrity r/t incontinence and decrease mobility aeb redness on buttocks and sacral area.
3. Nutrition less than body requirement r/t decrease food intake aeb pt stating she doesn’t like food and/or weight loss.
4. Risk for falls r/t decreased mobility.
5. Grieving r/t husband’s death aeb being mad at God and blaming God for his death.
Step 3: Type in the Data Clusters. Identify the Gordon’s Pattern and functionality; Analyze the data cluster to determine the problem. Identify the appropriate Nursing Diagnostic Label (nursing diagnosis). Complete the remaining sections. Include arrows showing how each data cluster/problem influences others on the care map. . Add, Expand, or Rearrange the boxes as needed.
Clustered Data (all relevant)
“I got very mad at God. How could He take my husband and leave me all alone? My husband used to take care of me”.
Relevant Gordon Pattern (name, functional or dysfunctional): Coping/stress Dysfuntional.
Associated Nursing diagnostic label: Grieving relating to husband’s death aeb pt stating blaming God for social isolation (Doenges, M.E. ET AL, 2019, P.384)
Clustered Data (all relevant)
Incontinent of bowel and bladder. Redness buttocks and a sacral area.
Relevant Gordon Pattern (name, functional or dysfunctional): Elimination or Dysfunctional.
Associated Nursing diagnostic label: Impaired skin integrity r/t incontinence aeb. Redness on buttocks and sacral infection.
Clustered Data (all relevant)
Unable to move on her own or ambulate. Dependent on staff for all her ADL.S.
Relevant Gordon Pattern (name, functional or dysfunctional): Acitivity/Exercise
Associated Nursing diagnostic label: Self care Deficit r/t decrease mobility aeb needing assistance with all ADL.S. Risk for fall r/t impaired mobility. (Doenges, M.E. et al, 2019, p.738).
Clustered Data (all relevant)
“I got very mad at God. How could He take my husband and leave me all alone”? My husband used to take care of me”.
Relevant Gordon Pattern (name, functional or dysfunctional): Value/Belief/Dysfunctional.
Associated Nursing diagnostic label: Spiritual Distress r/t being mad at god aeb feeling abandoned by husband and blaming God (Doenges, M.E. et al, 2019, p.832)
References
Doenges, M.E. Moorhouse, M.F., & Murr. A.C. (2019). Nursing diagnosis manual: planning individualizing, and documenting client care (6th ed.). F.A. Davis Company.
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