Kindly use medical terminology where neccesary

Kindly use medical terminology where neccesary

Case Study for Concept Map #6

Mr. D.A is a 74-year-old admitted to the hospital with a diagnosis of chest pain and congestive heart failure. He has a history of acute myocardial infarction, deep vein thrombosis, hypertension, diabetes mellitus, and arthritis. He reports “spasm-like” chest pain over his breastbone and difficulty “catching my breath.”

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These are the findings you assess

· Chest pain rated 4 on a scale of 0-10. “It feels like my heart is clenching like a fist – I am not sure I can call it pain.”

· VS T 99.3, P 102 and regular, R 30, B/P 172/100, his oxygen saturation is 90% on room air.

· Lungs have fine crackles throughout all lung fields

· 4+ pitting edema in bilateral ankles and feet

· Hgt 72 inches, Wgt 231 lbs

Mr. D. A. is on several medications for his congestive heart failure. “I take them exactly as they are ordered.” He is also to follow a low sodium diabetic diet. When you ask him what he has been eating he says “I don’t have time to cook the foods the doctor wants me to eat. I try to follow the diet, but I can’t live without Popeye’s fried chicken and biscuits.”

 

Concept map template

Nursing 110

Name:

Class:

Due Date:

Patient’s Initials:

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
HEENT (Head, Eyes, Ears, Nose, Throat)
Integument
Musculoskeletal
Cardiovascular
Respiratory
GI
GU
Emotional/Social/Spiritual
Reproductive

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)

 

Relevant Gordon Pattern: Health Perception/Health Management

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern:

Sleep/Rest

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern: Sexuality/Reproductive

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern: Value/Belief

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern: Cognitive/Perception

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern: Elimination

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern: Nutrition/Metabolic

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern: Activity/Exercise

Definition:

Clustered Data (all relevant)

Relevant Gordon Pattern: Coping/Stress

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern:

Self-Perception/Self-Concept

Definition:

Clustered Data (all relevant)

 

Relevant Gordon Pattern:

Role/Relationship

Definition:

Patient Name:

Age:

Gender:

Chief Complaint:

Clustered Data (all relevant)

 

Relevant Gordon Pattern (name, functional or dysfunctional):

 

Associated Nursing diagnostic label:

Patient Name:

Age:

Gender:

Situation:

Priority Nursing Diagnostic Statement:

Diagnostic Label

Related to

Evidence

Goal:

 

2-3 SMART outcomes:

1.

2.

3,

In your own words, based on the data cues, what is the most important (priority) problem?

List and prioritize all Nursing Diagnostic Statements (3 part or 2 part) based on data clusters above (at least 3):

1.

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)

 

 

 

Relevant Gordon Pattern (name, functional or dysfunctional):

 

Associated Nursing diagnostic label:

Clustered Data (all relevant)

 

 

 

Relevant Gordon Pattern (name, functional or dysfunctional):

 

Associated Nursing diagnostic label:

Clustered Data (all relevant)

 

 

 

Relevant Gordon Pattern (name, functional or dysfunctional):

 

Associated Nursing diagnostic label:

Clustered Data (all relevant)

 

 

 

Relevant Gordon Pattern (name, functional or dysfunctional):

 

Associated Nursing diagnostic label:

References