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Nursing Concept Map

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Ashley Jenkins

on 1 May 2014

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Transcript of Nursing Concept Map

Nursing Concept Map
Medical Diagnoses
Hypertension
ASHD
Anemia
Congestive Heart Failure
GERD
Abnormal Assessment
Findings
Dependent, non-pitting edema
Impaired mobility
Decreased grip and strength in right/left feet
Impaired vision
Impaired hearing
Incontinence and nocturia
Social withdrawal
Hearing Loss Related to Alternation in Sensory Reception, Transmission, and Integration
Related Factors/
Manifestations
Use of hearing aid in left ear
Without hearing aids, nurse needed to speak in right ear
Patient showed confusion when spoken to without the hearing aid
Nursing Diagnoses
Risk for Fatigue
Related Factors/
Manifestations
Disturbed sleep pattern from early waking
Decreased performance
Inability to maintain usual physical activity
Activity intolerance
Patient showed evidence of tiredness
Related to medical diagnosis of anemia
Social Isolation
Related Factors/
Manifestations
Factors contributing to the absence of satisfying personal relationships
Husband has declining health
Would not attend activities in dining room although she was physically able
Risk for Impaired Physical
Mobility
Related Factors/
Manifestations
Hx of left leg fracture increasing risk for falls
In wheelchair
Need of lift for transfers
Sedentary lifestyle
Decreased muscle strength
mainly left extremity; +2/5
Activity intolerance
Risk for Imbalanced Nutrition: Less than Body Requirements
Related Factors/
Manifestations
Decreased food intake and dissatisfaction of meals
Risk for Impaired
Skin Integrity
Related Factors/
Manifestations
Sedentary lifestyle and urinary incontinence
Mechanical factors during movement and transfer
Medications
Patient History
Expected Outcomes
Interventions
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Expected Outcomes
Interventions
Interventions
Interventions
Interventions
Interventions
Evaluations
Evaluations
Evaluations
Evaluations
Evaluations
Evaluations
Short-Term Goal:
Patient will verbalize and demonstrate selection of foods or meals that will achieve adequate nutrition by the end of the week
Long-Term Goal:
Patient will be free of signs of malnutrition for one month
Signs include: fatigue, muscle weakness, irritability, changes in vital signs, slow wound healing, changes in skin
Nurse will consult dietician regarding food preferences and nutritional support.
Nurse will encourage patient to keep a food diary to determine actual intake (percentages of foods eaten) for each meal.
Nurse will help patient identify desired nutritional foods to increase intake.
Nurse will encourage family to bring home-made food items as appropriate for her diet.
Client learned which foods about the proper nutrient dense foods to consume.
Client was able to identify which foods were nutrient dense foods.
Client stated the percentage of foods she consumed each morning, however she did not complete a food diary to record this information.
Client had a limited amount of snack-like foods that were brought in by family members
No full meals were brought in to client.
Short-Term Goal
:
Patient will verbalize less fear of falling and pain with physical activity by the end of shift.
Long-Term Goal
:
Patient will need limited assistance with her activities of daily living by the end of the week.
Nurse will encourage the patient to report pain level, making sure it does not increase to greater than 5/10 during passive range of motion exercises.
Nurse will use the Self-Efficacy for Exercise Scale and the Outcome Expectation for Exercise Scale to determine the client's self-efficacy and outcome expectations toward exercise.
Nurse will promote the patient to perform her ADLs on her own.
ADLs: brushing hair, brushing teeth, putting glasses on, getting dressed, etc.
Nurse will perform passive range of motion exercises with the patient twice daily (AM and bedtime) to increase the movement of her shoulder.
Client was able to perform ADL's on her own: brush teeth, hair, and put on glasses by herself.
Patient felt sense of self-worth and accomplishment in being able to perform ADL's.
Patient reported pain a 0/10 before passive ROM exercises were performed.
During exercises patient's facial expressions indicated pain, however no numerical value was reported.
Patient's ROM was not improved after the first week.
Short-Term Goal
:
Client will be able to identify potential causes of fatigue by the end of shift.
Long-Term Goal
:
Patient will verbalize increased energy and improved well-being by the end of the week.
Nurse will evaluate the adequacy of the patient's nutrition and sleep hygiene.
Nurse will encourage the client to identify recent losses and monitor for signs of depression as a possible contributing factor to fatigue.
Nurse will encourage the client to express feelings, attribution of cause and behaviors of fatigue, including potential causes, as well as possible interventions to alleviate fatigue.
Nurse will collaborate with primary care provider to identify potential pharmacological treatment for fatigue.
Short-term goal:
In one week the client will be able to identify why she feels socially isolated through verbalization with the nurse.
Long-term goal:
After 4 weeks the client will be able to participate in activities and programs with peers to a level of desire.
The nurse will observe for barriers of social interaction.
The nurse will note any risk factors that are causing the client's social isolation, such as psychological illness or physical deformity.
Nurse will help the client identify role models and encourage interactions with others who have similar interests through positive reinforcement.
Nursing staff will identify available personal support systems and involve those individuals in the clients care.
Short-Term Goal
:
In a few days, the patient will demonstrate to the nurse personal changes o advantage hearing.
Long-Term Goal
:
In three weeks, the patient will have others using techniques that advantage hearing and will therefore be able to understand speech in a more efficient manner.
The patient will explain to others to speak in a slow, distinct manner with appropriate volume. The nurse will assess the interactions between the patient and visitors each time the patient has a visitor. The nurse should measure, on a scale of 1-10, how well the patient understands the words being said.
The patient should request that interaction be in a low-stimulation environment. After the patient aids others in using techniques to advantage hearing, one should assess the interactions. One should assess the patient while the interactions occur. One may use a confusion scale (1-5. 1 showing no signs of confusion, 5 showing complete comprehension) to assess the level of confusion the patient may be displaying.
The patient will show proper use of hearing aids. Each day the doctor will check 3x a day to make sure the patient uses the aids. The nurse will count the number of times the patient does not wear the aid that day. If > 2, the intervention was not effective.
The patient will demonstrate to the nurse active listening techniques. The patient should be able to demonstrate how to position themselves, they should repeat phrases back to the speaker, and they should focus on the person speaking.
The client still has further work to do in order to complete the outcome. Although the patient showed the ability to explain to the visitors' techniques, the patient still only scored a 5/10 on the scale. The intervention may not be effective. Possible modifications may be needed.
The patient proves to be progressing great. being in a less stimulating environment proved to be efficient so the patient could narrow her focus on the incoming auditory stimuli from her visitors. She has scored higher each time she has a new interaction. We expect the intervention to be successful.
The patient shows great progress with the intervention. By the second day the patient had only forgot the hearing aid 1 time. The intervention proves to be effective and proper use will aid in comprehension of speech.
The patient had trouble showing all of the proper techniques. The deadline of the goal may need to be extended. I believe the patient to have trouble focusing on all of the proper active listening techniques. Possibly splitting up the techniques and analyzing them individually may prove to be more effect.
Short-Term Goal:
In a few days, the patient will be able to demonstrate an understanding of self-care activities.
Long-Term Goal:
In a month the perineal skin will remain intact and the patient will have no pain or discomfort in the perineal area.
Inspect the skin once a day to look for changes in skin color, texture, temperature, edema, damage, lesions, or dermatitis. If a lesion proves to be present, measure the lesion in millimeters and record your finding in the patient's chart.
Educate the patients on how important proper nutrition proves to be for skin integrity. The patient should make a diet plan to maximize their changes of keeping their skin intact. The patient should name the amount of calories, which foods to eat, and how much to eat.
Monitor the client's bodily skin practices. Note the temperature of the water, the amount and type of soap used, and the frequency the client cleans the skin.
Instruct the client about proper hand washing technique. Have them wash their hands for 20 seconds. The patient should wash the wrists, in between the fingers, the hands, and under the nails. The patient should be able to demonstrate the proper technique.
The patient did not have any signs of skin break down, showing the intervention to be effective. At any sign of potential breakdown, the workers took necessary measures to prevent issues. Due to superb intervention, the client shows great progress toward the outcome.
The patient did not show proper nutrition. The goal may need to be modified. If the patient cannot comply to the diet, restrictions may need to be placed. The outcome may be more difficult to reach with improper nutrition.
The patient shows great progress toward the outcome. She learned to avoid too frequent cleaning. She uses adequate skin practices and has shown no signs of skin breakdown. The intervention seems to be working to decrease the patient's risk of skin breakdown. The patient reports no irritation or pain.
The interventions for this goal proved to be effective. The goal helped the patient learn to avoid possible infection. The patient showed proper cleansing techniques. She proved to have impeccable progress with her cleansing strategies.
The nurse has identified the client's barriers to social interaction and has discussed them with the client which allowed the client to work on improving in these areas.
The client's hearing disability was identified as a major risk factor to social isolation, therefore the client now wears her hearing aid all of the time and can converse with people more readily, the intervention is working great.
The client identified role models which are available for the client to share feelings of distress with making her more open to conversation.
Client has found close friends through different support systems that have similar interests to hers, she now meets them every morning for coffee, the client is very happy with this outcome.
Intervention met by nursing staff and potential causes of her fatigue have been identified related to her nutrition and medical diagnoses.
Nurse discussed with the patient about potential losses or fears of loss related to her husband's declining health.
Intervention to be completed by nursing staff. Client will discuss with the nurse her thoughts on the causes and behaviors of fatigue and ways to alleviate it.
Intervention to be completed by nursing staff. Nurse will discuss possible pharmaceutical interventions to help treat the causes of the patient's fatigue. These could include her inadequate nutritional intake or her medical diagnosis of anemia.
Risk for Imbalanced Nutrition: Less than Body Requirements
Related Factors/
Manifestations
Decreased food intake and dissatisfaction of meals
Related Factors/
Manifestations
Hx of left leg fracture increasing risk for falls
In wheelchair
Need of lift for transfers
Sedentary lifestyle
Decreased muscle strength
mainly left extremity; +2/5
Activity intolerance
Related Factors/
Manifestations
Use of hearing aid in left ear
Without hearing aids, nurse needed to speak in right ear
Patient showed confusion when spoken to without the hearing aid
Risk for Fatigue
Related Factors/
Manifestations
Disturbed sleep pattern from early waking
Decreased performance
Inability to maintain usual physical activity
Activity intolerance
Patient showed evidence of tiredness
Related to medical diagnosis of anemia
Social Isolation
Related Factors/
Manifestations
Factors contributing to the absence of satisfying personal relationships
Husband has declining health
Would not attend activities in dining room although she was physically able
Related Factors/
Manifestations
Sedentary lifestyle and urinary incontinence
Mechanical factors during movement and transfer
Medications
Risk for Impaired
Skin Integrity
Hearing Loss Related to Alternation in Sensory Reception, Transmission, and Integration
Risk for Impaired
Physical Mobility
>65 years old, female
Married
Hx of fractured left femur
Fall risk
: high
Allergies:
atarax, eggs, latex, lisinopril, sulfa, Zestril, and Hetz
Admission date
: 2/22/13
Rationales
Monitor and record client's ability to tolerate activity by monitoring pain before and after activity (Ackley & Ladwig, p. 538).
Self-efficacy and outcome expectations should be assessed to optimize mobility and exercise in older women with a hx of post-hip fracture. The impact of fear of falling was greater 1 year post-hip fracture. Use of a fall assessment can help measure the fears of the patient (Ackley & Ladwig, p. 538).
Providing unnecessary assistance with ADL's promotes dependence and loss of mobility leading to helplessness (Ackley & Ladwig, p. 539).
Exercise helps reverse weakening and atrophy of muscles (Ackley & Ladwig, p. 539).
Rationales
If the client does not have her hearing aid in, she will be able to lip read and comprehend speech when others speak with a slow and distinct manner (Elsevier).
Over stimulation can increase disorientation. A disruption in the quality and/or quantity of stimuli may affect the patient's cognition. Too much sensory signals may block the important stimuli (auditory stimuli) (Elsevier).
One can enhance their hearing with proper volume of the aid, and with consistent use of the aid (Elsevier).
They should repeat the sentences because many numbers and words sound alike. Repeating helps the other party know if the patient hears correctly the sentences she receives. Effective listening will aid in the speed of processing and the working memory. Active listening may boost the patient's confidence in their communication skills and will prevent social withdrawal (Elsevier).
Rationales
Inadequate sleep or nutrition can contribute to or aggravate fatigue, especially if anemia is present (Ackley & Ladwig, p. 349).
There is a high correlation between depression and fatigue (Ackley & Ladwig, p. 351).
Cognitive-behavioral therapy has been shown to be moderately effective when compared to usual care and to relaxation, counseling, and educational support (Ackley & Ladwig, p. 350).
Pharmacological therapy has been shown to be effective in reducing fatigue (Ackley & Ladwig, p. 350).
Rationales
The causes of social isolation vary from person to person, therefore by identifying what is causing the social isolation the nurse can implement the appropriate intervention (Ackley & Ladwig, p. 753).
It is important to make the client as socially interactive as possible because studies show that social isolation is poor for one's health and can lead to inactivity, smoking, and multiple health damaging behaviors (Elsevier).
Developing relationships with others is difficult, but by interacting with others that have similar interests conversation flows easier and relationships are formed faster, therefore increasing the client's social skills (Elsevier).
Having family as the client's main support system provides the client with more comfort, safety, and encouragement while the client becomes more socially interactive (Ackley & Ladwig, p. 753).
Rationales
Systematic inspection can identify impending problems early (Ackley & Ladwig, p. 740).
Nutrition helps keep normal skin integrity and aids in tissue repair (Ackley & Ladwig, p. 739).
Hot water, acid pH, harshin cleansing agents, extreme friction, an too frequent cleaning can increase the risk of skin breakdown (Ackley & Ladwig, p. 739).
If the patient does get skin breakdown, proper hand washing will help prevent infection from occurring in the wound (Ackley & Ladwig, p. 739).
Rationales
May have a greater understanding of nutritional values of foods, so they may be able to help in assessing specific meals (Ackley & Ladwig, p. 558).
Use of a food diary is helpful for both the client and the nurse, to examine usual foods eaten, patterns of eating, and presence of deficiencies in diet (Ackley & Ladwig, p. 559).
Untreated malnutrition can result in multiple organ failure and death (Ackley & Ladwig, p. 559).
All people like to eat food that they are accustomed, especially when ill (Ackley & Ladwig, p. 560).
References

Ackley, B.L., Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to planing care. (10th ed.). Maryland Heights: Mosby Elsevier.

EHS: Nursing Diagnosis Care Plans, 4/e- Communication, Impaired Verbal. (n.d.). Retrieved April 29, 2014, from http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archieve/Constructor/gulanick12.html
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