solved

*** the patient is —
PATIENT FOR Concept map
HISTORY OF PRESENT PROBLEM:
Patient is Joan Walker; she is 84 years old. She has had a productive cough which is green in color for the past 4 days. Her PCP (primary care provider) started her on Prednisone 40 mg daily and Azithromycin (Zithromax) 250 mg PO for 5 days which she started 3 days ago. She has had intermittent chills, a fever last night of 102F/38.9C and has increased shortness of breath especially in the evening and during the night. She is using her albuterol inhaler about every 1-2 hours which does not seem to be working. She called 911 and is now in your ER and you are the nurse responsible for her care.
PERSONAL/SOCIAL HISTORY:
Joan is a widow for the past 6 months, after being married for 64 years and is currently living in a SNF (skilled nursing facility). Taught as anelementary school teacher for over 30 years in the local community. She is active in her church and called her pastor who can with her to the ER. You walked in as the pastor asked Joan if she would like to pray. Joan replied to the pastor “yes please I feel that this may be the beginning of the end for me”
Current vital signs T: 103.2F/39.6, P 110 regular, R 30 labored and using accessory muscles, BP 178/96, O2 sat 86% on 6 liters of oxygen via nasal cannula, P-Q-R-S-T Pain Assessment Provoking: deep and shallow breathing, Quality: ache, Radiation: generalized pain over right side of chest no radiation, Severity: 3/10, Timing: Intermittent last a few seconds
CURRENT ASSESSMENT:
General Appearance: appears anxious and in distress, barrel chest observed
Respiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally anterior and posterior with scattered expiratory wheezing
Cardiac: Pale hot and dry, no edema, heart sounds regular S1 S2 pulse strong equal with palpation at radial/pedal/post-tibial landmarks
Neuro: Alert and orientated to person, place, time, and situation (x4)
GI: Abdomen soft nontender bowel sounds audible per auscultation in all 4 quadrants
GU: Voiding without difficulty, urine clear
Skin: intact turgor elastic and no tenting visible
Fluid and Electrolytes/Lab/ Diagnostic results
Chest x-ray: left lower lobe infiltrate with hypoventilation present in both lung fields
Lab: WBC (4.5-11.0) hers: current is 14.5 prior was 8.2
Hgb (12-16g/dL) current 13.3 prior was 12.8
Platelets (150-450×103/ul) current 217 prior was 298
Neutrophil % (42-72) current 92 prior was 75
Band for (3-5%) current 5 prior was 1
Here is more lab data:
Basic Metabolic Pane. (BMP):
Sodium (135-145 mEq/L) current 138 prior 142
Potassium (3.5-mEq/L5) current 3.9 prior 3.8
CO2 (Bicarb) (21-31mmol/L) current 35 prior 31
Glucose (70-110 mg/dL) current 112 prior 102
BUN (7-25 mg/dL) current 32 prior 28
Creatinine (0.6-1.2) current 1.2 prior 1.0
Lactate (0.5-2.2 mmol/L) current 3.2 prior NA
ARTERIAL BLOOD GAS (ABG):
pH (7.35-7.45) current 7.25
pCO2 (35-45) current 68
pO2 (80-100) current 52
HCO3 (bicarb) (18-26) current 36
O2 sat (>92%) current 84%
What is the ABG interpretation?
HERE IS THE PATIENT’S MEDICATION
Lorazepam 2.5 mg every 6 hours as needed for anxiety
Atorvastatin 600 mg twice a day
Enalapril 10 mg daily
Albuterol MDI 2 puffs every 4 hours PRN
Salmeterol/fluticasone Diskus (Advair) 1 puff every 12 hours
Triamterene-HCTA (Dyazide) 1 tablet daily
Reflection what did I learn from this? ****
*DIRECTIONS ****
Preparing the assignment
Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.
1. Choose an individual for whom you have cared in the clinical setting.2. Create a concept map based on the complete physical assessment you performed while providing care using the provided power point template. a. Components of the concept mapi. Individual’s information (10 points/10%)1. Age2. Medical diagnosis3. Brief review of underlying pathophysiology
*List what functional changes are happening
*List process that initiated and maintained disorder or disease
ii. Assessment Data (15 points; 15%)1. Include all assessment data, not simply information that supports the selected nursing diagnoses
Inspect
Palpation
Percussion
Auscultate
Neurological Exam
iii. Nursing Diagnoses (15 points/ 15%)1. Select three nursing diagnoses to addressesa. One must be an actual problemb. One must address a psychosocial needc. The final must be a high priority for the individualiv. Linkages Within and Between Diagnoses (5 points/5%)1. Concept map demonstrates relationship within and between the nursing diagnoses.v. Planning (15 points/15%)1. Prioritize diagnoses to reflect needs of the individual2. Set realistic outcome measurement3. At least two (2) scholarly, primary sources from the last 5 years, excluding the textbook, are providedvi. Implementation (15 points/15%)1. Interventions are individualized for patient-provide rationale2. Interventions support achievement of selected outcome measurements-provide rationale
vii. Evaluation of Outcomes (5 points/15%)1. Determine if outcomes were met.2. Provide evidence that supports that determination.3. Describe what changes, if any, are needed to promote expected outcomes in the future.viii. Safety-Communication-Infection Control 16 points/16%)a. specific elements of communication used when providing care,b. safety concerns related to the individual for whom you cared, andc. infection control practices followed while caring for this patient.ix. APA Citations and Writing (4 points/4%)a. References are submitted with assignment.b. Uses appropriate APA format and is free of errors.c. Grammar is free of errors.d. Spelling is free of errors.
viii. Safety-Communication-Infection Control 16 points/16%)a. specific elements of communication used when providing care,b. safety concerns related to the individual for whom you cared, andc. infection control practices followed while caring for this patient.
ix. APA Citations and Writing (4 points/4%)
Safety
Communication
Infection Control
Image transcription text
4 Student 4:24 PM Fri Jan 21 uandfcidei l0
Medical Diagnoses Pathophysiclogy review
Assessment Data Patient initials:… Show more
Please fill the map off the patient information… thanks
And a reference page… make it Apa format

*** the patient is — PATIENT FOR Concept map HISTORY OF PRESENT PROBLEM: Patient is Joan Walker; she is 84 years old. She has had a productive cough which is green in color for the past 4 days. Her PCP (primary care provider) started her on Prednisone 40 mg daily and Azithromycin (Zithromax) 250 mg PO for 5 days which she started 3 days ago. She has had intermittent chills, a fever last night of 102F/38.9C and has increased shortness of breath especially in the evening and during the night. She is using her albuterol inhaler about every 1-2 hours which does not seem to be working. She called 911 and is now in your ER and you are the nurse responsible for her care. PERSONAL/SOCIAL HISTORY: Joan is a widow for the past 6 months, after being married for 64 years and is currently living in a SNF (skilled nursing facility). Taught as anelementary school teacher for over 30 years in the local community. She is active in her church and called her pastor who can with her to the ER. You walked in as the pastor asked Joan if she would like to pray. Joan replied to the pastor “yes please I feel that this may be the beginning of the end for me” Current vital signs T: 103.2F/39.6, P 110 regular, R 30 labored and using accessory muscles, BP 178/96, O2 sat 86% on 6 liters of oxygen via nasal cannula, P-Q-R-S-T Pain Assessment Provoking: deep and shallow breathing, Quality: ache, Radiation: generalized pain over right side of chest no radiation, Severity: 3/10, Timing: Intermittent last a few seconds CURRENT ASSESSMENT: General Appearance: appears anxious and in distress, barrel chest observed Respiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally anterior and posterior with scattered expiratory wheezing Cardiac: Pale hot and dry, no edema, heart sounds regular S1 S2 pulse strong equal with palpation at radial/pedal/post-tibial landmarks Neuro: Alert and orientated to person, place, time, and situation (x4) GI: Abdomen soft nontender bowel sounds audible per auscultation in all 4 quadrants GU: Voiding without difficulty, urine clear Skin: intact turgor elastic and no tenting visible Fluid and Electrolytes/Lab/ Diagnostic results Chest x-ray: left lower lobe infiltrate with hypoventilation present in both lung fields Lab: WBC (4.5-11.0) hers: current is 14.5 prior was 8.2 Hgb (12-16g/dL) current 13.3 prior was 12.8 Platelets (150-450×103/ul) current 217 prior was 298 Neutrophil % (42-72) current 92 prior was 75 Band for (3-5%) current 5 prior was 1 Here is more lab data: Basic Metabolic Pane. (BMP): Sodium (135-145 mEq/L) current 138 prior 142 Potassium (3.5-mEq/L5) current 3.9 prior 3.8 CO2 (Bicarb) (21-31mmol/L) current 35 prior 31 Glucose (70-110 mg/dL) current 112 prior 102 BUN (7-25 mg/dL) current 32 prior 28 Creatinine (0.6-1.2) current 1.2 prior 1.0 Lactate (0.5-2.2 mmol/L) current 3.2 prior NA ARTERIAL BLOOD GAS (ABG): pH (7.35-7.45) current 7.25 pCO2 (35-45) current 68 pO2 (80-100) current 52 HCO3 (bicarb) (18-26) current 36 O2 sat (>92%) current 84% What is the ABG interpretation? HERE IS THE PATIENT’S MEDICATION Lorazepam 2.5 mg every 6 hours as needed for anxiety Atorvastatin 600 mg twice a day Enalapril 10 mg daily Albuterol MDI 2 puffs every 4 hours PRN Salmeterol/fluticasone Diskus (Advair) 1 puff every 12 hours Triamterene-HCTA (Dyazide) 1 tablet daily Reflection what did I learn from this? —This is my patient information—- *** attached is the different student sample on different patient*** that you could get clue
Image transcription text
Nursing Diagnosis related to –. Nursing
Diagnosis related to –. as evidence by–
Nursing Diagnosis related to –. a… Show more

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