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Nursing Concept Map

Clinical client concept map.

Ambrosia Haines

on 5 January 2013

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Transcript of Nursing Concept Map

Nursing Concept Map Ambrosia Haines SY
64 Female
Admit Dx: Parkinson's
Disease History Vital Signs Nursing Diagnosis #2 Nursing Diagnosis #3 Nursing Diagnosis #1 Imbalanced Nutrition
the effects of excessive intake in relation to metabolic need
Obesity Impaired physical
Rigidity, bradykinesia, and akinesia
Difficulty in initiation of purposeful movements. Chronic Sorrow
the effects of chronic physical disability.
Patient states that she is depressed Pathophysiology Assessment Medications BACLOFEN - Skeletal muscle relaxant - Prescribed for clients muscle spasms. Side effects: dizziness, weakness, fatigue, drowsiness, seizures, CNS, coma, and nausea. Contraindications: hypersensitivity.

ESCITALOPRAM (Lexapro) - Antidepressant SSRI - Prescribed for clients depression. Side effects: headache, nervousness and insomnia. Contraindications: hypersensitivity to this product.

GABAPENTIN - Anticonvulsant - Prescribed for clients neuropathy. Side effects: drowsiness, confusion, depression, seizures, and leukopenia. Contraindications: hypersensitivity.

DIAZAPAM (Valium) - Antianxiety, anticonvulsant, skeletal muscle relaxant - Prescriped for clients muscle spasms. Side effects: dizziness, drowsiness, orthostatic hypotension, and blurred vision. Contraindications: hypersensitivity to benzodiazepines, closed angle glaucoma, myasthenia gravis, ethanol intoxication, hepatic disease and sleep apnea. BP - 126/70
Pulse - 79
Respirations - 20
Temperature - 97.4 (oral)
O2 Stats - 97%
Pain - 6 (on a scale of 1 - 10) Parkinson's disease (PD) is a common chronic degenerative disease of the central nervous system that produces progressive movement disorders and changes in cognition and mood. It's hallmarks include a pill-rolling tremor of the hands, muscular rigidity, loss of facial expression, difficulty initiating movements (akinesia, bradykinesia), and gait disturbances (especially shuffling gait, festination, and sometimes difficulty initiating forward movements). Parkinson's disease is usually found in people over the age of 65. It's underlying cause is unknown; it is clear, however, that dopamine production by brain cells in the substantia nigra is dimished in the disease. Although PD often clusters in families, it is uncertain wheter this is the result of genetics or of expossure to common precipitating agents (viruses, toxins, or drugs). In the U.S. about 1.5 million people have PD, with about 50,000 new cases diagnosed each year. Short Term Goals Long Term Goal Client will use physical exercise appropriately to deter muscle atrophy and joint contractures. Assist to develop an exercise plan that incorporates an orderly sequence of stretching movements, consistent with level of musculoskeletal fitness, to reduce rigidity and increase ROM. Plan for patient to participate in care when medications are at peak level. Consult with physical therapy for exercises and assistive devices to maximize independence with self care activities. Client will use assistive devices appropriately for increased mobility, and ambulation by end of shift. Assist patient with initial ambulation to determine degree of impairment. Assist client with proper use of wheelchair. Assist client to use footwear that facilitates walking and prevents injury. EVALUATION Client ambulation was severely compromised because of muscle weakness and acute pain in bilateral knees. Client should be assessed for motorized wheelchair because she admits she doesn't have the muscle strength in bilateral hands for a manual wheelchair. Risk Factors Limited physical activity
Limited mobility
Fall risk due to muscle weakness
Poor diet
Old age
Recent cataract surgery in both eyes limits vision Client was living independently in a small apartment and receiving minimal weekly assistance from family and friends with her ADLs. She was admitted to the hospital for hematemesis, and was not able to return to independent living because of her severe muscle tremors in her R hand, muscle spasms in bilateral legs, and increased falls. Client also has osteoarthritis of her bilateral knees, which decreases her mobility even further, and increases her pain. She suffers from obesity and depression related to her decreased mobility and independence due to Parkinson's disease. Client is currently attending physical therapy twice a week, and reported an increase in muscle strength overall. EVALUATION Alert and oriented x 4. Client reports stabbing pain in bilateral knees 6 out of 10, but is responsive and cooperative during physical assessment. Clients eyes are perrla. She responds appropriately to verbal stimuli; extreme slurring of speech due to PD, and poorly fitted dentures. Feeds self with minor assistance, but states that it is becoming more challenging as she loses muscle strength in her hands. Skin is acyanotic and loose. No skin breakdown noted. Hair is dark, short and thinning but appears healthy. Respirations are even and unlabored; breath sounds clear to auscultation throughout all lung fields. Apical pulse regular rate and rhythm; s1, s2 noted. Abdomen soft & nondistended with bowel sounds active in all 4 quadrants. Pink nailbeds with capillary refill <2 seconds in all extremities. +1 edema in both feet and ankles. Has difficulty moving all extremities, but extreme difficulty with R side extremities. Hand grips weak and unequal: weakest on right. Client is on scheduled toileting due to the need for a two person assist. She has a history of UTIs, client states that it is related to "poor peri care and having to hold in urine while waiting for assistance to urinate." Urine clear yellow. All signs of PD are present: tremors, rigidity, akinesia and postural instability. Client tolerated physical assessment well. Labs All labs were within normal ranges.
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