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JC Care Plan Client Concept Map Packet Final
Medical-Surgical Nursing II (NSG 223)
Herzing University
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NSG223 Medical Surgical Nursing II Care Plan & Client Concept Map Packet Name:
Date:
Instructions:
During the NSG223 Medical Surgical Nursing I course students will complete a total of four care plan/map assignments as follows:
- 1 Care Plan/ Client Concept Map based on virtual or simulation patient (Care Plan Part II* & Part IV; Client Concept Map Parts I-IV).
- 1 Client Concept Map based on virtual or simulation patient (Client Concept Map Parts I - IV) *
- 1 Care Plan/ Client Concept Map based on clinical facility patient (Care Plan Part II* & Part IV; Client Concept Map Parts I- IV)
- 1 Client Concept Map based on clinical facility patient (Client Concept Map Parts III - IV) *
- if they receive a score >90% on their #3 Assignment; Otherwise Assignment #4 will include Care Plan Part II and Part IV; Client Concept Map Parts I, III, & IV
** Must include relevant evidence to support use of 3 most relevant medications in client case.
Care Plan/Client Concept Map Components: All components available to students for the purpose of data collection and organization.
Care Plan Part I: Basic Conditioning Factors (Optional) Care Plan Part II: Medications (Required #1 and #3 above) * Care Plan Part III: Diagnostic Studies & Interpretation (Optional) Care Plan Part IV: Physical Assessment (Optional) Client Concept Map Part I: Assessment/Recognize Cues (Required #1 and #3 above) * Client Concept Map Part II: Nursing Diagnoses & Plan (Required #1 and #3 above) * Client Concept Map Part III: Concept Map Client Concept Map Part IV: Abbreviated Nursing Diagnosis & Plan
NSG223 Medical Surgical Nursing II Care Plan & Client Concept Map Packet Name:
Date:
Nursing Care Plan Part I: Basic Conditioning Factors Date: A. Patient identifiers: JC Physician (s): Alice Gomez MD Age: 75 Gender: F Ht: 66 Wt. 143 lbs Code Status: Full Isolation: Standard
Development Stage (Erikson): Give the rational for your evaluation
Health States Date of admission: 5/28/ Activity level: Diet: Fall risk: Yes
Client’s description of health status (define chronic state)
Client’s past medical surgical history (include dates)
Allergies: (include type of reaction) None
Surgical history None
Completed therapies:
Current therapies:
Socio-cultural Orientation Cultural and Ethnic Background: African American
Socialization:
Family system Elements (Support system) Married
Spiritual: Christian
Occupation (across the lifespan): Retired-retail clerk
Patterns of living: (define past and current
Part II: Medications
List all medications, dosages, classifications and the rational for the medications prescribed for this patient include major considerations for administration and the possible negative outcomes associated with this medication. (May include additional copies of this form as needed)
** Must include evidence to support use of 3 most relevant medications in client case.
ALLERGIES:
Medication & Classification
Dosage Purpose/Mechanism of Action
Contraindications, Adverse Reactions/Side Effects; Risk Factors, Nursing Implications; & Patient Education
**Relevant Research Findings/Evidence to support treatment for this client. Link to Article/Evidence Below
Hydrochlorothiazide Thiazide Diuretic, antihypertensive
PO adult/teens: 12- 25mg/day Geriatric: 12/day
Increases the release/removal of water, sodium, potassium and chloride from the body through the kidneys
Contraindications:
Preeclampsia Renal/hepatic disease Gout COPD Diabetes mellitus anuria
SE/AE:
dizziness fatigue weakness headache orthostatic hypotension blurred vision nausea vomiting urinary frequency renal failure glucosuria
Used for edema, hypertension, diuresis, heart failure
hyperuricemia
PT Teaching:
rise slowly from lying or sitting notify if you have muscle weakness, cramps, nausea, dizziness or rash take with food or milk use sunscreen take early in the day at the same time avoid alcohol monitor weight and notify of changes take BP
Nitroglycerin Coronary Vasodilator, Antianginal
SL: 1 tablet every 5 minutes while pain/discomfort lasts (total 15 minutes if you need 3 tabs)
Works to reduce preload and afterload to help dilate arteries and improve blood flow.
Contraindications:
Cardiomyopathy Constrictive pericarditis Cardiac tamponade Increased intracranial pressure
SE/AE: headache, flushing, dizziness, tachycardia, nausea, vomiting, syncope and palpitations
PT Teaching:
Place between lip and gum and allow to dissolve completely Keep in original container Keep away from heat and light Seek medical attention if you still have pain/discomfort after
Used for chronic stable angina, heart failure, acute myocardial infarction
Part III: DIAGNOSTIC STUDIES AND INTERPRETETION
LAB Normal values
Initial results
Most current results
How is this related to the disease process?
Pertinent nursing interventions, if applicable
What expected assessment findings correlate with this result?
HEMATOLOGY
CBC
WBC
RBC
HGB
HCT
PLATLETS
WBC
Differential
Polys
Bands
Lymphocytes
Monocytes
Eosinophils
GBC indices
MCV
MCH
MCHC
Bilirubin
Occ. Blood
Bilirubin
WBC
RBC
Epithelia
WBC
RBC
Epithelial Cells
Bacteria
Hyaline Casts
Gran Casts
Leukocytes
Nitrite
ACCUCHECK
CHEMISTRY
Glucose
BUN
Cr
GFR
Na
K
CO
Ca
Phosphorus
Normal values
Initial results
Most current results
How is this related to the disease process?
Pertinent nursing interventions, if applicable
What expected assessment findings correlate with this result?
Amylase
Lipase
Uric Acid
Protein
Albumin
Cl
Enzymes
LDH
CPK
SGOT
SGPT
Troponin I
Myoglobin
Cholesterol
Triglycerides
Endoscopy
Additional information:
13
CARE PLAN PART IV: PHYSICAL EXAM
Vital Signs/Pain/Pulse Ox: Temp: 99F_ Location: O, A, R, T Apical Pulse: Rate = 90 (initial)80 (reassess) BPM; Rhythm: Regular Irregular/erratic Thready Bounding Strong Respirations: Rate = 21 (initial) 15 (reassess); Rhythm: Even Regular Irregular Labored Strained Moderate Shallow Deep With stridor / retractions / apnea noted Blood Pressure: 148/88_; Arm: R / L; Patient’s Position: Lying / Standing / Reclining / _Sitting_______ Pain: Scale (1 - 10) _6; Nonverbal cues: ________________; Loc: ____; Onset: this morning; Duration: ____________; Quality: ____________________ Client states, “It feels heavy like an elephant is sitting on my chest.”
Neuro: LOC: Alert & Oriented X: 1, 2, 3; Oriented to: Person, Place, Time; Disoriented to: Person, Place, Time Affect/Mood: Alert, Flat Affect, Tearful, Confused, Pleasant, ________________ Glascow Coma Scale: Total Score= ____; Eyes, open 4=Spontaneously, 3=to speech, 2=to pain, 1=n/a Verbal Response: 5=oriented, 4=confused, 3=inappropriate words, 2=incomprehensible sounds, 1=n/a Motor Response: 6= obeys commands, 5=localized pain, 4=flexion w/drawl, 3=abnormal flexion, 2=abnormal extension, 1=flaccid Pupil Size & Reaction: PERRLA, unequal, misshapen, unreactive to light, no accommodation Vision: Left = / Right = _/__, Nearsighted, Farsighted, Astigmatism (L or R) Corrective lenses: Glasses, Contacts, Abnormal findings: _____________________________ Hearing: Normal, Loss (L or R) Degree: ____________, Hearing aid, Pain, Ringing Rushing Communication: Lucid Coherent Incoherent Slurred speech ________________ Facial Symmetry: Symmetrical Unsymmetrical (location) ______________ Client states,
Cardiac: Heart sounds: clearly audible, muffled at A, P, E, T, M Sounds are: with free of murmursand / or gallops PMI: Location of palpation = ___________________ Apical Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Brachial Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Temporal Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4) Carotid Pulse: Rate = ____ BPM; Rhythm: Regular Irregular/erratic; Strength: Thready (+1) Weak (+2) Normal (+3) Bounding (+4)
NSG223 Medical Surgical Nursing II Care Plan & Client Concept Map Packet Name:
Date:
CLIENT CONCEPT MAP- PART 1 –RECOGNIZE CUES Identify relevant and important objective & subjective information from different sources (e. medical history, vital signs). Include both pertinent positives and pertinent negatives. What information is most important? What is of immediate concern?
PRIMARY ADMITTING DIAGNOSIS AND DEFINITION:
Angina is the chest pain felt as a result of the demand for oxygen exceeds the available supply needed to the heart.
PATHOPHYSIOLOGY OF PRIMARY DIAGNOSIS SENSORIMOTOR SYSTEM: DX
SUBJECTIVE
The patient is experiencing chest pain unrelieved by nitro Sudden pain and heaviness in chest
OBJECTIVE Elevated blood pressure of 148/ 96% O RR: 15 bpm Pulse 100 bpm
SUBJECTIVE
Chest pain that comes and goes Pain is worse than normally 7 out of 10
OBJECTIVE Elevated blood pressure of 148/ Pulse 100 bpm RR: 21 bpm
SUBJECTIVE
None
OBJECTIVE
Neurologically intact Extraocular movements within normal range Pupils are 4mm and reactive
Respiratory SYSTEM: DX
NUTRITION/REGULATORY: DX NOT ASSESSED
ELIMINATION SYSTEM: DX NOT ASSESSED
SUBJECTIVE
No difficulty breathing
OBJECTIVE
SUBJECTIVE
Not Assessed
SUBJECTIVE
Not Assessed
CLIENT CONCEPT MAP- PART II-PRIORITY PATIENT PROBLEMS PLAN OF CARE:
ANALYZE CUES PRIORITIZE HYPOTHESIS GENERATE SOLUTIONS TAKE ACTIONS EVALUATE OUTCOMES
Analyze Cues: Organize and linking the recognized cues to the client’s clinical presentation.
What client conditions are consistent with the cues?
Oxygenation problems:
Elevated heart rate Chest pain Increased respiratory rate when pain occurs
What other information would help establish the significance of a cue or set of cues?
Electrocardiogram Stress test Echocardiogram Arterial Blood Gases
Evaluating and ranking hypotheses according to priority (urgency, likelihood, risk, difficulty, time, etc.)
Based on analysis, which explanations are most/least likely or are the most serious?
Most Serious: Increased oxygen demand and no enough oxygen supply
This is the identification of your priority patient problems. Identify your top 4 patient priorities here:
- Treat angina
- Relieve pain
- Relieve anxiety
- Avoid complications from angina
Identify expected outcomes and using hypotheses to define a set of interventions for the expected outcomes.
What are the desired outcomes related to your #1 priority patient problem? List a minimum of three.
- The patient will verbalize relief of pain and discomfort within 30 minutes.
- The patient will show no signs of worsening angina by the end of shift.
- The patient’s labs will show no signs of myocardial damage by the end of shift.
What should be avoided?
Smoking Large meals Excessive stress Excessive strenuous activities Obesity Saturated and trans fats
Implementing the solution(s) that addresses the highest priorities.
*What interventions can achieve the outcomes listed for your #1 priority patient problem? List a minimum of three interventions for each outcome. (note: potential solutions could include collecting additional information).
- Maintain oxygen saturation above 95% by continuing supplemental oxygen via nasal cannula
- Assist the patient in maintaining a semi/high fowlers position
- Reassess vital signs
- Educate the patient of what is going on and why.
How should each of the
Comparing observed outcomes against expected outcomes.
What signs point to (or would point to) improving or declining status for each of the selected interventions?
No reports of chest pain or discomfort Decreased respiratory rate within normal range Decreased heart rate within normal range No cyanosis No shortness of breath
Based on the signs noted, were the interventions effective?
N/A
Would other interventions
selected interventions be accomplished (performed, requested, administered, communicated, taught, documented)?
Monitor vital signs to determine if increase supplemental oxygen is needed Monitor skin for cyanosis Reassess patient’s pain Educate the patient on the different ways in which we are attempting to rebalance the supply and demand for oxygen
have been more effective?
If the angina remained a problem she would have needed surgical interventions.
*note: the selection of interventions is part of generating solutions – the actual implementation of interventions is a part of taking action.
GENERATE SOLUTIONS TAKE ACTIONS EVALUATE OUTCOMES
Avoid stress
(patients) not listening to their body when pain/discomfort occurs
Discussing an acceptable pain level for patient if other interventions aren’t working until a provider can see them for advance interventions.
*note: the selection of interventions is part of generating solutions – the actual implementation of interventions is a part of taking action-
Reference List (may include Care Plan Resources/Guides, Content in Realize It, Lippincott Advisor, or content in the POINT student resource area)
CLIENT CONCEPT MAP PART III (EXAMPLE)
Example: Diabetes Mellitus (with associated etiology and pathogenesis)
Top 4 Priority Patient Problems (examples) #1 Potential for Erratic Blood Glucose Levels due to inadequate blood glucose monitoring, periodic illness, dietary intake. #2 Potential for Local & Systemic Infection due to chronic inflammation and hyperglycemia. #3due to #4due to
JC Care Plan Client Concept Map Packet Final
Course: Medical-Surgical Nursing II (NSG 223)
University: Herzing University
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