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Nursing Concept Map

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Amanda Black

on 30 April 2015

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Transcript of Nursing Concept Map

Nursing Concept Map
Care Plan: P.S.
Age:
63
Sex:
Female
Unit:
LTC; Rehabilitation
Primary Medical Diagnosis:
Ciliac disease
Medical history:
Cancer; Metastasis of melanoma to brain and bowel; treated with resection and radiation in 2002.
Hypothyroidism
Cholecystectomy
Osteoperosis
Bowel obstruction, treated with lysis of adhesions.
Decisional Conflict R/T moral principles, rules, and values supporting mutually inconsistent course of action AEB difficulty deciding who will take control of house.
Subjective Data:
Client reports "I just don't know what to do." concerning the decision of who will take control of her house.

Objective Data:
Client vacillates between alternative choices. Client shows physical signs of tension and distress; restlessness, worried expression.
Risk for dysfunctional Gastrointestinal Motility R/T abdominal surgery, Pharmaceutical agents (opioids) and Food intolerance (gluten)
Subjective data:
Client reports absolute constipation before obstructive bowel surgery.

Objective data:
Client had bowel surgery, client is taking Percocet for pain, client has been diagnosed with Celiac disease, Client has hypoactive bowel sounds.
Risk for Falls R/T use of assistive device (walker) and acute illness; post-operative conditions.
Subjective Data:
Client communicates weakness and fatigue.
Objective Data:
Client uses an assistive device, her gait is unsteady and her balance impaired.
Risk for Loneliness R/T affectional deprivation physical and social isolation and cathectic deprivation.
Objective data:
Client seems uninterested in other residents and keeps to herself in her room most of the time.
Subjective data:
Client reports a poor relationship with her son and daughter-in-law and is fearful that her greatest friendship may fail.
Health Perception and
Health Management
Nutrition, Skin/
Elimination
/ Values and Beliefs
Cognitive Perceptual
/ Activity, Exercise/ Sleep, Rest
Role Relationship /Sexuality/
Self-Perception
/ Coping Stress
Long Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Short Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Short Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Long Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Short Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Long Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Short Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Long Term Goal:
Nursing Intervention 1:
Nursing Intervention 2:
Nursing Intervention 3:
Client will identify individual difficulties and ways to address them by the end of the shift.
Independent:
Nurse will establish nurse-client relationship.

Client may feel free to talk about feelings in context of an empathetic relationship.
Collaborative:
Nurse will refer to appropriate counselors for help with relationship between son and daughter-in-law.
Client will engage in social activities; client will eat dinner in the dining room tonight and come up with a group function she would like to attend in one week.
Independent:

Nurse will identify individual areas of interest that provide opportunities for involvement with others.

Independent:
Nurse will support expression of negative perceptions of others and note whether client agrees.

Provide opportunity for client to clarify reality of situation, recognize own denial.

Independent:
Nurse will encourage attendance at support group activities to meet individual needs.

Provides a social setting for interpersonal interaction.

Independent:
Nurse will help client establish plan for progressive involvement, beginning with simple activity and leading to more complicated interactions and activities.
Client will verbalize understanding of individual risk factors that contribute to the possibility of falls and think of ways to mitigate risks by the end of the shift.
Independent:
Nurse will evaluate client's current disorders/ conditions that could enhance the risk potential for falls.
Independent:
Nurse will evaluate misuse or failure to use assistive aids.

Client may have assistive device, but is at high risk for falls while adjusting to altered body state and use of unfamiliar device; or client may refuse to use devices for various reasons.

Independent:
Nurse will consider hazards in the care setting and home environment.

Identifying needs or deficits provides opportunities for intervention and instruction.


Client will be free of injury upon discharge from facility.
Independent:
Nurse will review medication regimen and how it affects client. Instruct in monitoring of effects and side effects.

Use of certain medications can contribute to weakness, confusion, and balance and gait disturbances. Reviewing medication and side effects with client may reduce risk of falls.

Independent:
Nurse will clear environment of hazards.

Moving obstructing furniture, electrical cords, clothes on the floor, spills, etc. will decrease the risk for falls.

Collaborative:
Nurse will refer to rehabilitation team (physical therapy) as appropriate.

To improve clients balance, strength and mobility and to identify and obtain appropriate assistive devices for environmental safety.

Client will verbalize understanding of individual risk factors and benefits of maintaining condition by the end of the shift.
Independent:
Nurse will review with client measures to maintain bowel health.

Use of dietary fiber/ stool softeners, fluid intake, maintaining regular bowel evacuation habits, emphasize benefits of regular exercise.


Independent:
Nurse will emphasize importance of discussing with physician current and new prescribed medications and/ or planned use of certain medications (e.g., NSAIDS, corticosteroids and some OTC and herbal supplements.

These can be harmful to GI mucosa.

Independent:
Nurse will recommend and/ or refer to physician for vaccines as indicated.

The CDC makes recommendations for travelers and/ or persons in high-risk areas or situations in which persons might be exposed to contaminated food or water.
Client will maintain normal pattern of bowel functioning throughout stay at Paramount.
Independent:
Nurse will discuss with client normal variation in bowel patterns.

This will help alleviate unnecessary concern, allow implementation of planned interventions or seek timely medical care.

Independent:
Nurse will emphasize importance and assist with early ambulation, especially following surgery.

This is to stimulate peristalsis and help reduce GI complication associated with immobility.
Independent:
Nurse will ascertain whether client is experiencing anxiety, stress or other psychogenic factors.

These factors may contribute to GI upset and dysfunction.
Client will acknowledge and ventilate feelings of anxiety and distress associated with making this decision by following week.
Independent:
Nurse will use active listening to identify reason for indecisiveness.

Helps client to clarify problem and work toward solution.

Independent:
Nurse will accept verbal expression of anger or guilt, setting limits on maladaptive behavior.

This will promote client safety and trust.
Nurse will identify strengths and presence of positive coping skills (e.g., use of relaxation technique, willingness to express feelings.)

Client will make decision and express satisfaction with choice one week prior to discharge.
Independent:
Nurse will discuss with client time considerations, setting time line for small steps and considering consequences related to not making/ postponing decision.

To facilitate resolution of conflict.

Independent:
Nurse will have client list some alternatives to present decision using a brainstorming process. Nurse will include family in this process if client agrees.
Collaborative:
Nurse will refer to other resources as necessary (e.g., clergy, psychiatric clinical nurse specialist/ psychiatrist, family therapist, social worker, etc.)


Evaluation
Evaluation
Evaluation
Evaluation
Evaluation
Evaluation
Evaluation
Evaluation
Client has met this goal. She has proper knowledge of how to use her walker. She communicates a need for staff to leave her walker closer to her bed if thy move it. Client attends Physical Therapy twice per day to strengthen her core and improve balance.
Client met this goal upon first discharge, further evaluation is needed to determine success of this goal on future discharge.
Client has met this goal. She is very knowledgeable about her disease and it meticulous about eating foods that are gluten free. She is also very diligent about monitoring her GI system and informing staff of anything out of the ordinary. She understands that her medication and other factors may cause problems to watch for.
Client has, to this point, maintained normal pattern of bowel function. Further evaluation will be needed to determine if this goal is met by discharge.
Client has met this goal. She is very adept at expressing her feelings and frustrations about things with which she is struggling. She expresses her concerns and fears very articulately but has a unique ability to stay upbeat and in good spirits about things.
Nurse was unable to make this evaluation before the end of clinical rotation, however, client seemed determined to place her assets in the care of her son who, despite their tendency to not get along, she felt would be the most honest in amusing the responsibility.
Client has not met this goal completely. She states that the other residents are crazy and she doesn't like to spend time with them. She states that she likes the staff but often the staff is very busy. Client has not expressed any ideas about ways to address her isolation.
Nurse has identified client's religious affiliation to be LDS and has informed the client that relief society meetings are held several times per week. Client has not discussed interest in this activity and has expressed little interest in eating in the dining room.

Nurse has encouraged client to make frequent calls to friends and family outside the facility and to reach out to her ward bishop for opportunities for visits.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 595). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013). Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales (Ed. 13. ed., p. 564). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 365). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013). Nurse's pocket guide:
Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 365). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 366). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., pp. 367). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 435). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 436). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 435). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 435). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 307). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 308). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 308). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 594). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 595). Philadelphia, PA: F.A. Davis.
Doenges, M., Moorhouse, M., & Murr, A. (2013).
Nurse's pocket guide: Diagnoses, prioritized interventions, and rationales
(Ed. 13. ed., p. 436). Philadelphia, PA: F.A. Davis
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