Concept MapStudent Name:
Instructor:
Erickson’s Developmental Stage Related to pt. & Cite
References (1)
None
Patient Education (In Pt.) & Discharge Planning (home needs)
History of Present Illness (HPI), Pathophysiology of Admitting Dx
(Cite References) Medical, Surgical, Social History (1).
Enough rest
No carrying of heavy load
Medical History
none
Cultural considerations, ethnicity, occupation, religion,
family support, insurance. (1) (14)
Socioeconomic/Cultural/Spiritual Orientation &
Psychosocial Considerations/Concerns, to include
the following Social Determinants of Health
❋Economic Stability
❋ Education
❋Social and Community Context ❋ Health and Health Care
❋ Neighborhood and Built Environment
Diagnostic Test/ Lab Results with dates
and Normal Ranges (3)
Test
Norms
Date
Blood test
7/7/19
Urine test
7/7/19
Hepatic
Function
Test
8/7/19
Current
Value
Patient Information
Chief Complaint
(1)
Name:
Age:
Gender:
Code Status:
DPOA:
Living Will:
abdominal infection/ diverticulitis
Admitting Diagnosis
Abdominal infection
Soft tissue infection
Medical Management/ Orders/ Medications & Allergies (2)
Name
Dose
Imodiu
m
bismut
h
aceta
minop
hen
RT
Freq.
MOA
RN
Considerations
1*2
Daily
None
None
Onset/Peak
/Duration
(Insulin)
None
1*2
Daily
None
None
None
1*2
Daily
None
None
None
Surgical History
none
Social History
none
Priority nursing diagnosis #1
Abdominal pain
Vital Signs (4)
Pain
Neurological (5)
None
Nutrition/Hydration
(8)
Normal
GI (9)
Normal
Cardiovascular (6)
Respiratory (7)
Present
Priority nursing diagnosis #2
Soft tissue infection
Present
Rest/ Exercise (11)
NEEDED
GU (10)
Normal
Outcome/Goal #1
Establish the cause
Outcome/Goal #2
Diagnose the infection
Integumentary (12)
Normal
Endocrine (13)
Normal
Psychosocial (14)
Normal
Misc. (Ht/Wt)
Normal
Interventions # 2
Blood test and Hepatic Function Test
Interventions #1
Blood and urine tests
Assessment/ Evaluation #2
Assessment/ Evaluation #1
Normal pain
No blood infections
PC Outcomes/Goal
Potential Complications/ at
risk for
None
Pulmonary collapse
Soft tissue infections
Normal pain
PC Interventions
Detoxification
Pain killers
Enough rest
PC Evaluation Plan
Admit
0
esc
tab
Nursing care plan
Priority Nursing Diagnosis #1
Electrolyte imbalance related to inability to winate sufficiently
as evidenced by abnormal lab value.
Vital signs 14).
The Vital signs related to hypertension and diabetes,
HR-an
outcome/Goal #
RR-32
T-101.2
BP- 140/110
feeling fatigue.
On – 95%
Patient will be able to walk
Ą loop around the unit with out
Priority nursing diagnosis #2
Activity intolerance related to poor perfusion as evidenced
by early onset of fatigue.
outcome / Goal #2
Lab values to be within normal range by the end of the
Shift.
Potassium-3.5-5.5
Sodium-135-145
– NAnition/ Hydration (8)
History of stroke free diet
Jow sodium low far dies
clecreased saturated fats and and sodium
pt constantly dehydrated needs daily 1500-2,500ml of fluid
m
bismut 12
h
aceta
12
minop
Daily
hen
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GI (1)
? ni
Constipation, reflux abdominal pain, naused, diarrhed, dysphagia,
increase appetite.
Integumentary (12)
liter
ICF
due to being
medication
as prescribed
.
Mainting Propea Avid volume
at a functional level (28-32)
pt. is prone to skinbreakdown
immobile
Redness and thinning of
the Skin
Sacran
around the
Psychosocia)/14)
– Memory and cognitive difficulties
Depression
– Anxiety
sodium levels.
2) Monitor Patients serm
Collaborate
the role of sodium
3) Educate the patient and family
about
In the body
Coping skills
DE With dretary to make
Sure pt. is on a low
Misc. (Ht/wt)
Sodium dicto
Height 5’ll
Weight- 180
4. Intervention #4
Monitor Patient for fatigue parlenes, tachycardis), and bleeding
teburka
murnis
hock
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3
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Q
Interventions #1
to collaborate with physical therapy to improve patient’s mobility.
2. Administer blood pressure medication
3. Adminster digretios
4. Educate patient on why they need physical activity.
Assessment | Evaluation #1 and #2
For Both: Goal Met.
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Cardiovascular (6)
Priority nursin
Soft tissue infect
Respiratory (1)
Present
Priority nursing diagnosis #1
Abdominal pain
Neurological (5)
None
Vital Signs (4)
Pain
Present
X
Rest/ Exercise (11)
NEEDED
GU (10)
Normal
GI (9)
Normal
Nutrition/Hydration
(8)
Normal
Outcom
missing or unclear, please ask the tutor
fore you review the tutor.
Diagnose 1
Outcome/Goal #1
Establish the cause
Psychosocial (14)
Normal
Misc. (H/W
Normal
Endocrine (13)
Normal
Integumentary (12)
Normal
ng Studypool’s integrated content checker
ferences, ask for these to be submitted
Inter
Blood test and
Interventions #1
Blood and urine tests
Assessment/ Evaluation #2
en the file and that the formatting is
the format or file type is incorrect.
Normal pain
Assessment Evaluation #1
Normal pain
No blood infections
CONTINUE
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