adult health
Damoche
Revisedconceptmaptemplatensg240245430-113.pptConcept map template
DAMILOLA OLOYEDE
Nsg 240/245/430
Assessment
Subjective: complain of pain upon admission
objective data: leg edema, stage 2 pressure injury, right heel, right leg tear
Vital signs: BP 112/63, HR 69, RR 18, Temp 97.7. pulse ox 68, pain 8 on a scale of 0 to 10
Body Systems
Respiration; 18, clear lung sound
Cardiovascular; BP 112/63, HR 69, pulse palpation and +2 heart sound s1s2 and regular.
Integumetary; leg edema, stage 2 pressure injury right heel, right leg tear.
Urinary; condom catheter, orange clear.
Neuro/Sensory/Mental alert; alert and oriented x3
HEENT; hearing adequate, eyes PERRLA
GI; Abdomen is soft, symmetric, and non tender without distention.
Gordon Pattern and cluster data
Patient is confused and very forgetful
Relevant Gordon Pattern:
Self-Perception/Self-Concept
Definition:
A person’s behavior about self, viewpoint of abilities, body image, recognition, general sense of value, and emotional patterns style (Doenges et. Al. , 2013, p. 17).
Dysfunctional
Gordon Pattern and cluster data
Patient is stressed and in acute pain
Relevant Gordon Pattern: Coping/Stress
Definition: Universal coping style, stress tolerance, support systems, and perceive ability to control and manage issues (Doenges et. Al. , 2013, p. 17).
Dysfunctional
Gordon Pattern and cluster data
Patient has diarrhea and incontinence
Relevant Gordon Pattern: Nutrition/Metabolic
Definition: Style of food and fluid consumption, fluid and electrolyte balance, overall capacity to recover (Doenges et. Al. , 2013, p. 17
Dysfunctional
Patient
JB
90yo Male
Gordon Pattern and cluster data
Patient has a condom catheter in place
Relevant Gordon Pattern: Elimination
Definition:
Styles of excretory function (bowel, bladder, and shin) and client’s viewpoint (Doenges et. Al. , 2013, p. 17).
Dysfunctional
Gordon Pattern and cluster data
Patient cannot walk without assistance and also needs assistance to be transferred from bed to his wheelchair
Relevant Gordon Pattern: Activity/Exercise
Definition: Pattern of training ,undertaking, spare time, relaxation, and activities of daily living; factors that impede with desired or expected individual style (Doenges et. Al. , 2013, p. 17).
Dysfunctional
Medications
Escitalopram 10mg/PO/Selective Serotonin Reuptake Inhibitor SSRI. Side effect; coma, confusion, decreased urine output.
Pantoprazole/40mg/ IV/proton-pump inhibitor. Side effects joint pain, gas
Metoprolol 25mg/PO/Beta blocker. Side effect; dry mouth, depression, bloating
List doctors order
Blood work
Clear liquid diet
Condom catheter
Fall risk precaution
Labs/xrays
WBC 10.52 abnormal (high) indicating an infection
Hgb 8.6 abnormal (low)
CBC test showed Hematocrit 29.8 abnormal (low) anemia
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Pathophysiology
Abdominal pain due to Gastrointestinal bleeding. This is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is not apparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia.
Intervention and rational
Assess vital signs, particularly blood pressure level: Hypovolemia due to GI bleeding may lower pressure levels and put the patient at risk for hypotensive episodes that can lead to shock.
Evaluation
Goals were met
Patient report no pain upon discharge
Goal/outcome
Patient will have a blood pressure level within range
Psychosocial Nsg Dx
Ineffective health maintenance related to lack of knowledge about signs and symptoms of GI bleed stating, “visible blood in stool and rectal bleeding”.
Physiological Nsg Dx
Acute abdominal pain related to patient holding abdomen due to GI bleed as evidenced by patient stating pain level is 10 on a scale of 0-10, 10 being worse
Goal/outcome
Patient will have an absence of GI bleeding and a hemoglobin level of over 13
Goal/outcome
Pain management
Patient reports 0 level of pain on a scale of 0-10
Intervention and rational
Commence a fluid balance chart monitoring the input and output of the patient: To monitor patient’s fluid volume.
Intervention and rational
Educate the patient on how to fill out a fluid balance: To encourage the patient to drink more fluid as needed or report any changes to the nursing team
Evaluation
At the time of the evaluation, there was increase in the patients overall well being.
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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:
- Explain how the data clusters helped you to determine the Gordon’s Functional and Dysfunctional Patterns.
- 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.
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?
Answer questions
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References
Doenges, E. M. ,Moorhouse, F. M. (2013). Application of nursing process and nursing diagnosis
(6th ed.). DavisPlus
Kim, B. S., Li, B. T., Engel, A., Samra, J. S., Clarke, S., Norton, I. D., & Li, A. E. (2014). Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World journal of gastrointestinal pathophysiology, 5(4), 467–478. https://doi.org/10.4291/wjgp.v5.i4.467
DiGregorio AM, Alvey H. Gastrointestinal Bleeding. [Updated 2020 Aug 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537291/
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