The document is a concept map for a patient named Yveline Fortilus. It summarizes the patient's condition, diagnoses, treatment plan, and nursing care. The admitting diagnosis is acute diarrhea. Key findings include generalized edema, decreased breath sounds, and loose bowel movements. The priority nursing diagnosis is deficient fluid volume related to prolonged diarrhea. The goal is for the patient to maintain fluid volume at a functional level in three days. The plan includes medication administration and monitoring lab results and symptoms to evaluate fluid status.
The document is a concept map for a patient named Yveline Fortilus. It summarizes the patient's condition, diagnoses, treatment plan, and nursing care. The admitting diagnosis is acute diarrhea. Key findings include generalized edema, decreased breath sounds, and loose bowel movements. The priority nursing diagnosis is deficient fluid volume related to prolonged diarrhea. The goal is for the patient to maintain fluid volume at a functional level in three days. The plan includes medication administration and monitoring lab results and symptoms to evaluate fluid status.
The document is a concept map for a patient named Yveline Fortilus. It summarizes the patient's condition, diagnoses, treatment plan, and nursing care. The admitting diagnosis is acute diarrhea. Key findings include generalized edema, decreased breath sounds, and loose bowel movements. The priority nursing diagnosis is deficient fluid volume related to prolonged diarrhea. The goal is for the patient to maintain fluid volume at a functional level in three days. The plan includes medication administration and monitoring lab results and symptoms to evaluate fluid status.
Deficient fluid volume related to prolonged diarrhea secondary infectious processes.
Key Data & Analysis (from attached worksheet) Cardiovascular S: -Regular heart beat:76/mn -generalized non pitting edema -pale skin and mucous membrane Respiratory S: -Unlaboured breathing - decreased air entry to the base/ expiratory wheezes Gastrointestinal S -hyperactive bowel sounds/slightly distended abdomen/ passing flatus/ 10 loose BM on June 1/ Genitourinary S Urine output <50ml/hr Integumentary Non elastic skin/ stage 2 pressure ulcer wound on coccyx 2. Plan Relevant Diagnostic Tests: CBC Electrolyte Albumin level Serum lactate level c-difficile toxin urinalysis chest x ray Relevant Psych/Social Analysis (Mental Health): Pt is in the late adulthood Pt is not oriented to time and place Pt is calm and cooperative/irritable at time Pt received phone calls from family(daughter and son) all the time
3.Implementation Priority Goal (Health Outcome) related to nursing diagnosis. (SMART) The client will maintain fluid volume at a functional level in three days.
IPC Team Client Care Priorities: Control the Diarrhea SW: Discharge planning Chaplain: spiritual care OT/PT: ROM /transfer practice
1. Assessment (Priority) (Please attach worksheet*) Relevant Medications, Clinical Indications & Nursing Implications: (Appendix if needed) 1. Asa 5- dalteparin 2. Metronidazole 6- clodipogrel sulphate 3. Vancomycin 7-potassium gluconate 4. Bisoprolol (Please see attach for clinical indications) Nursing Interventions: (For priority nursing diagnosis) & citations: 1. Review the patients lab test result Rationale: to evaluate the degree of fluid loss and determine replacement need (Carpenito, 2013).
2. Administer scheduled medication as prescribed Rationale: Medication s such as metronidazole and vancomycin are used in the treatment of C-difficile infection (Doenges, Moorhouse and Murr, 2013. 3. Observe patient for any elevation of temperature , cough, crackles on the chest Rationale: fluid correction may compromised the cardiovascular system causing fluid overload (Doenges, Moorhouse and Murr, 2013,
Teaching Plan: Attach Appendix: 4. Evaluation of health outcome related to goal Data & Analysis: 1- Goal met. By monitoring patient lab result nurse realized that patient has hypokalemia and has notified the doctor. 2- Goal met. After one day of administration of scheduled medications patient has a reduction of 4 pasty BM a day. 3- Goal met. The patients vital signs remain stable. Urine output increased to 65ml/hr.
Relevant Medical Plan of Care: (Not diagnostic tests) 1- Control the infection 2- Integration of patient back to the retirement home 3- Supportive care measures
*GBC Health Assessment Data Collection Form: Part A & Part B Concept Map Student: Yveline Fortilus__________________ Page 2
Additional Nursing Diagnoses: (in order of PRIORITY) Priority Goals:
1. Acute pain related to infectious disease process secondary to C-Difficile as evidenced by client verbal report of pain in the abdomen The client will verbalize a decrease in pain intensity in the next two hours.
2. Impaired skin integrity related to effects of pressure and constant maceration in the coccyx area The client will demonstrate progressive healing of the pressure ulcer in four days.
3. Risk for loneliness related to therapeutic isolation secondary to C- difficile infection The client will not show any signs of loneliness today.
Please note: See Marking Rubric for Concept Maps; 3/15 marks are allocated for discussion of your concept map with your faculty advisor (i.e. explaining rationale)
References: (APA 6 th edition):
Carpenito, L. J.(2013). Nursing Diagnosis: Application to clinical practice (14th ed). Lippincott Williams & Wilkins
Collin, P. H. (2005). Dictionary of Medical Terms. London: A & C Black.
Doenges, M.,& Moorhouse,M., & Murr, A. C. (2013). Nursing Diagnosis Manual Planning, Individualizing, and Documenting Client care. Retrieved September 19, 2013 from http://www.scribd.com/doc/33812048/76/readiness-for-enhanced-Self-Care
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