Question Answered step-by-step  Concept Map AssignmentFOR THIS PAPER YOU ARE EXPECTED TO:USE A HOLISTIC APPROACH TO DEVELOP A SCENARIO BASED ON YOUR ASSIGNED RESIDENT’S ADMITTING, CURRENT, AND ONGOING HEALTH ISSUES.USE THE CONCEPT MAP FORMAT.ONLY USE ONE NANDA PER PAGE JUST LIKE THE STUDENT EXAMPLE (YOU SHOULD HAVE 4 OF THESE PAGES TO FULFILL NANDA REQUIREMENTS)INCLUDE:FOUR INDIVDUALIZED PRIORIZED NANDA(S)REMEMBER, YOUR ASSIGNED RESIDENT HAS ACTUAL PROBLEMS AS OPPOSED TO JUST POTENTIAL AND RISK FORNO LESS THAN “FOUR” PRIORITIZED INTERVENTIONS FOR EACH NANDAPLEASE INCLUDE YOUR NURSING GOALS FOR EACH NANDA (1 LONG-TERM AND 1 SHORT-TERM)EVALUATIONS (DID THE RESIDENT COMPLETE THE GOALS/OR WILL THEY BE ABLE TO COMPLETE THE GOALS BASED ON THE SCENARIO?)   . ASSIGNED RESIDENT’S ADMITTING, CURRENT, AND ONGOING HEALTH ISSUES.Patient IntroductionLocation: Neurological Unit 0800SBAR report from the night nurse:Situation: Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had a head CT and received thrombolytic therapy in the ED. He is nothing by mouth except for medications until the speech therapist has completed a bedside evaluation, which is scheduled for later this morning. He is scheduled for physical therapy later today.Background: Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise.Assessment: We have already checked his blood glucose level this morning. His vital signs have been stable and he slept well last night. He was able to get up to go to the bathroom with the use of a walker. His neurological checks are stable and he continues to have mild left hemiplegia. His hand grasps are almost equal but a little weaker on the left side. His pupils are equal and react to light. Swallow reflex is intact. He is oriented x3. I have already done a Morse Fall Risk assessment with a total high risk score of 60.Recommendation: You should do a vital signs assessment, perform a neurological assessment, and talk about safety with Mr. Russell. You should also provide patient education on risk and prevention of aspiration. His morning medications are up and should be administered.  USE THE CONCEPT MAP FORMAT. Nursing Diagnosis: Ineffective peripheral tissue perfusion r/t impaired transport of oxygen across alveolar membrane evidenced by dyspnea and edema.    Goals & Outcomes:   Resident will identify factors that improve circulation by the end of shift.Resident identifies necessary lifestyles changes by discharge.Resident will show no further worsening of deficitsResident maintains maximum tissue perfusion to vital organs by having warm, dry skin and absence of edema. Client’s Medical  Dx(s) and Assessment Data: Deep vein thrombosis 76 years old female                                          BP: 125/82 Temp: 97.8F HR:81 RSP:18 Pulse OX:97% in room air      Evaluation: Resident feels comfortResident pain will lessenResident will show no sign of deep vein thrombosis; signs include pain, tenderness, swelling or redness in the lower extremity.Resident engages active range of monition on her own  Nursing Interventions with EBP Rationales Elevate head of bed 30 to 45 degrees, evidence-based practice states that this promotes venous outflow from brain and helps reduce pressure (Hanison., 2017).Provide compression stockings. Prevents blood clot (Hanison., 2017)Float heels on pillows on bed every shift for pressure relief (Hanison., 2017)Provide rest periods between care activities and prevent duration of procedures. Constant activity can further increase cranial pressure by creating a cumulative stimulant effect (Vasylii, et al., 2017)Promote active/passive range of motion exercises. Exercise prevents venous stasis and further circulatory compromise (Vasylii, et al., 2017)Position patient properly in semi-fowler’s to high fowlers as tolerated. Upright positioning promotes improved alveolar gas exchange (Hanison, 2017).                                      Health Science Science Nursing HEALTH SCI NURSING102 Share QuestionEmailCopy link Comments (0)

Question Answered step-by-step  Concept Map AssignmentFOR THIS PAPER YOU ARE EXPECTED TO:USE A HOLISTIC APPROACH TO DEVELOP A SCENARIO BASED ON YOUR ASSIGNED RESIDENT’S ADMITTING, CURRENT, AND ONGOING HEALTH ISSUES.USE THE CONCEPT MAP FORMAT.ONLY USE ONE NANDA PER PAGE JUST LIKE THE STUDENT EXAMPLE (YOU SHOULD HAVE 4 OF THESE PAGES TO FULFILL NANDA REQUIREMENTS)INCLUDE:FOUR INDIVDUALIZED PRIORIZED NANDA(S)REMEMBER, YOUR ASSIGNED RESIDENT HAS ACTUAL PROBLEMS AS OPPOSED TO JUST POTENTIAL AND RISK FORNO LESS THAN “FOUR” PRIORITIZED INTERVENTIONS FOR EACH NANDAPLEASE INCLUDE YOUR NURSING GOALS FOR EACH NANDA (1 LONG-TERM AND 1 SHORT-TERM)EVALUATIONS (DID THE RESIDENT COMPLETE THE GOALS/OR WILL THEY BE ABLE TO COMPLETE THE GOALS BASED ON THE SCENARIO?)   . ASSIGNED RESIDENT’S ADMITTING, CURRENT, AND ONGOING HEALTH ISSUES.Patient IntroductionLocation: Neurological Unit 0800SBAR report from the night nurse:Situation: Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had a head CT and received thrombolytic therapy in the ED. He is nothing by mouth except for medications until the speech therapist has completed a bedside evaluation, which is scheduled for later this morning. He is scheduled for physical therapy later today.Background: Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise.Assessment: We have already checked his blood glucose level this morning. His vital signs have been stable and he slept well last night. He was able to get up to go to the bathroom with the use of a walker. His neurological checks are stable and he continues to have mild left hemiplegia. His hand grasps are almost equal but a little weaker on the left side. His pupils are equal and react to light. Swallow reflex is intact. He is oriented x3. I have already done a Morse Fall Risk assessment with a total high risk score of 60.Recommendation: You should do a vital signs assessment, perform a neurological assessment, and talk about safety with Mr. Russell. You should also provide patient education on risk and prevention of aspiration. His morning medications are up and should be administered.  USE THE CONCEPT MAP FORMAT. Nursing Diagnosis: Ineffective peripheral tissue perfusion r/t impaired transport of oxygen across alveolar membrane evidenced by dyspnea and edema.    Goals & Outcomes:   Resident will identify factors that improve circulation by the end of shift.Resident identifies necessary lifestyles changes by discharge.Resident will show no further worsening of deficitsResident maintains maximum tissue perfusion to vital organs by having warm, dry skin and absence of edema. Client’s Medical  Dx(s) and Assessment Data: Deep vein thrombosis 76 years old female                                          BP: 125/82 Temp: 97.8F HR:81 RSP:18 Pulse OX:97% in room air      Evaluation: Resident feels comfortResident pain will lessenResident will show no sign of deep vein thrombosis; signs include pain, tenderness, swelling or redness in the lower extremity.Resident engages active range of monition on her own  Nursing Interventions with EBP Rationales Elevate head of bed 30 to 45 degrees, evidence-based practice states that this promotes venous outflow from brain and helps reduce pressure (Hanison., 2017).Provide compression stockings. Prevents blood clot (Hanison., 2017)Float heels on pillows on bed every shift for pressure relief (Hanison., 2017)Provide rest periods between care activities and prevent duration of procedures. Constant activity can further increase cranial pressure by creating a cumulative stimulant effect (Vasylii, et al., 2017)Promote active/passive range of motion exercises. Exercise prevents venous stasis and further circulatory compromise (Vasylii, et al., 2017)Position patient properly in semi-fowler’s to high fowlers as tolerated. Upright positioning promotes improved alveolar gas exchange (Hanison, 2017).                                      Health Science Science Nursing HEALTH SCI NURSING102 Share QuestionEmailCopy link Comments (0)