*** the patient is PATIENT FOR Concept map HISTORY OF PRESENT…
Question Answered step-by-step *** the patient is PATIENT FOR Concept map HISTORY OF PRESENT… *** the patient is — PATIENT FOR Concept mapHISTORY 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 secondsCURRENT ASSESSMENT:General Appearance: appears anxious and in distress, barrel chest observedRespiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally anterior and posterior with scattered expiratory wheezingCardiac: Pale hot and dry, no edema, heart sounds regular S1 S2 pulse strong equal with palpation at radial/pedal/post-tibial landmarksNeuro: Alert and orientated to person, place, time, and situation (x4)GI: Abdomen soft nontender bowel sounds audible per auscultation in all 4 quadrantsGU: Voiding without difficulty, urine clearSkin: intact turgor elastic and no tenting visibleFluid and Electrolytes/Lab/ Diagnostic resultsChest x-ray: left lower lobe infiltrate with hypoventilation present in both lung fieldsLab: WBC (4.5-11.0) hers: current is 14.5 prior was 8.2 Hgb (12-16g/dL) current 13.3 prior was 12.8Platelets (150-450×103/ul) current 217 prior was 298Neutrophil % (42-72) current 92 prior was 75Band for (3-5%) current 5 prior was 1Here is more lab data:Basic Metabolic Pane. (BMP):Sodium (135-145 mEq/L) current 138 prior 142Potassium (3.5-mEq/L5) current 3.9 prior 3.8CO2 (Bicarb) (21-31mmol/L) current 35 prior 31Glucose (70-110 mg/dL) current 112 prior 102BUN (7-25 mg/dL) current 32 prior 28Creatinine (0.6-1.2) current 1.2 prior 1.0Lactate (0.5-2.2 mmol/L) current 3.2 prior NAARTERIAL BLOOD GAS (ABG): pH (7.35-7.45) current 7.25pCO2 (35-45) current 68pO2 (80-100) current 52HCO3 (bicarb) (18-26) current 36O2 sat (>92%) current 84%What is the ABG interpretation?HERE IS THE PATIENT’S MEDICATIONLorazepam 2.5 mg every 6 hours as needed for anxietyAtorvastatin 600 mg twice a dayEnalapril 10 mg dailyAlbuterol MDI 2 puffs every 4 hours PRNSalmeterol/fluticasone Diskus (Advair) 1 puff every 12 hoursTriamterene-HCTA (Dyazide) 1 tablet dailyReflection what did I learn from this? *****DIRECTIONS ****Preparing the assignmentFollow 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 diseaseii. Assessment Data (15 points; 15%)1. Include all assessment data, not simply information that supports the selected nursing diagnosesInspectPalpationPercussionAuscultateNeurological Examiii. 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 text4 Student 4:24 PM Fri Jan 21 uandfcideil0 Medical Diagnoses Pathophysiclogyreview Assessment Data … Show more… 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 mapHISTORY 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 secondsCURRENT ASSESSMENT:General Appearance: appears anxious and in distress, barrel chest observedRespiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally anterior and posterior with scattered expiratory wheezingCardiac: Pale hot and dry, no edema, heart sounds regular S1 S2 pulse strong equal with palpation at radial/pedal/post-tibial landmarksNeuro: Alert and orientated to person, place, time, and situation (x4)GI: Abdomen soft nontender bowel sounds audible per auscultation in all 4 quadrantsGU: Voiding without difficulty, urine clearSkin: intact turgor elastic and no tenting visibleFluid and Electrolytes/Lab/ Diagnostic resultsChest x-ray: left lower lobe infiltrate with hypoventilation present in both lung fieldsLab: WBC (4.5-11.0) hers: current is 14.5 prior was 8.2 Hgb (12-16g/dL) current 13.3 prior was 12.8Platelets (150-450×103/ul) current 217 prior was 298Neutrophil % (42-72) current 92 prior was 75Band for (3-5%) current 5 prior was 1Here is more lab data:Basic Metabolic Pane. (BMP):Sodium (135-145 mEq/L) current 138 prior 142Potassium (3.5-mEq/L5) current 3.9 prior 3.8CO2 (Bicarb) (21-31mmol/L) current 35 prior 31Glucose (70-110 mg/dL) current 112 prior 102BUN (7-25 mg/dL) current 32 prior 28Creatinine (0.6-1.2) current 1.2 prior 1.0Lactate (0.5-2.2 mmol/L) current 3.2 prior NAARTERIAL BLOOD GAS (ABG): pH (7.35-7.45) current 7.25pCO2 (35-45) current 68pO2 (80-100) current 52HCO3 (bicarb) (18-26) current 36O2 sat (>92%) current 84%What is the ABG interpretation?HERE IS THE PATIENT’S MEDICATIONLorazepam 2.5 mg every 6 hours as needed for anxietyAtorvastatin 600 mg twice a dayEnalapril 10 mg dailyAlbuterol MDI 2 puffs every 4 hours PRNSalmeterol/fluticasone Diskus (Advair) 1 puff every 12 hoursTriamterene-HCTA (Dyazide) 1 tablet dailyReflection what did I learn from this?—This is my patient information—-*** attached is the different student sample on different patient*** that you could get clueImage transcription textNursing Diagnosis related to –. NursingDiagnosis related to –. as evidenceby– Nursing Diagnosis rel… Show more… Show more Health Science Science Nursing NR 226 Share QuestionEmailCopy link Comments (0)
