11 Jun B.A 60yrs old,female full code, admitted may 6 for lower abdominal pain(9month), secondary diagnose, hyperkalemia, history diabetes,hypertension, hyperlipidemia
B.A 60yrs old,female full code, admitted may 6 for lower abdominal pain(9month), secondary diagnose, hyperkalemia, history diabetes,hypertension, hyperlipidemia,migraines,bipolar,anxiety. first vital signs was 132/72, HR 76, TEMP. 98.2, SPO2 98, RESP R.17, BLOOD glucose 282 was high after an 1hour vital and also after the medication 118/70 spo 95, Hr 78, Temp 97.6, rr, 17 blood glucose 242. pottassium level was high 7.1, doctors order Glucose AC& HS, Diabetic diet, Diabetic teaching, SCD.
medication
topamax,insulin lispro, gabapentin,seroquel,amlodipine,sodium bicarbonate,inslin aspart 70/30& protamine.metoprolol, oxycodene actemapohine.
please include references,i put in an example there to follow please, and it uses turnitin.
Patient
Name: B.H
DOB: 12/22/1957
Age: 64 y/o
Preferred Language: English
Code Status: Full Code
Allergies: Iodine, Penicillin, Percocet, Oxycodone-Acetaminophen
Situation: Medical Dx/ Pathophysiology:
Peripheral Edema:
clinical manifestation of an accumulation of fluid within the interstitial spaces of the body. It develops when the normal balance between the flow of fluid out of capillaries and the return of fluid to the vascular space via capillary reabsorption and lymphatic flow is disrupted.
Labs/Xrays
Vital Signs:
BUN: 28 level high
Glucose Test: 168 Hyperglycemic
Calcium: Within Range
Sodium: 137 Within Range
Creatinine: 1.5 level high
CO2: 28 Within Range
Chloride: 102 Within Range
Potassium: 4.1 Within Range
Medications
-Gabapentin(NEURONTIN) capsule 200mg oral every 8hrs for neuropathic pain. Side effects of gabapentin are Feeling sleepy, tired, dizzy, nausea, vomiting, diarrhea, Swollen arms and legs and Blurred vision. (Burchum & Rosenthal, 2019).
-Aspirin Chewable tab 81mg, blood thinner salicylate and a nonsteroidal anti-inflammatory drug (NSAID)
-Amlodipine (Norvasc) 2.5 mg, decreased blood pressure
-Hydralazine tablet 29mg
Atorvastatin QHS 80mg reduce LDL
Bumetanide 2 x day 0.5mg diuretic/urination
Bupropion BID 75mg antidepressant
Carvedilol BID 25mg antihypertensive, take with food 2 tabs a day.
List of Doctors Order:
-Vital Sign: Q8
-Chest Xray
-Blood Glucose
-Echo Cardiogram Complete
-Lung Scan perfusion only
-US Vein Duplex UE Unilateral
Pertinent Medical History
-Chest Pian 12/28/18
-Syncope 12/28/18
-Cardiomyopathy 12/28/18
-Coronary Artery Disease 12/28/18
-DKA 1/28/20
-Altered Mental Status 1/28/20
-Metabolic Acidosis 1/30/20
-Peripheral Edema 3/23/22
-CVA 3/23/22
-TIA 3/23/22
-Lactic Acidosis 2/26/20
-Sever Sepsis 1/30/20
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Assessment
Subjective: Patient has a pain to left upper and lower extremity, two person assist patient today with ADL. Patient is allergies to Penicillin's, respond verbally when asked, and patient was calm and cooperative when providing care. patient BG was 123- 7:23am.
Objective data: 64/ y-o female diagnosis Peripheral Edema with history of Pulmonary embolism, CVA, TIA.
Body System
Cardiovascular: Hr- 81, BP-175/78, Capillary refill is less than 3 second bilaterally, S1S2 present, it is a regular rate rhythm, no murmur, rubs or gallops.
Respiratory: RR- 18,02-98%
Neurological: patient is alert and oriented to person, time, place, and situation, Patient strength is 5/5 in the left upper extremity upon inspection and ROM, but movement is affected due to pain in left lower extremity. Eyes reacted to light, pupils equal, round, reactive to light, and accommodation, intake and output, no edema.
Integumentary: No Bruising noted, no rashes, Patient skin warm, no wound noted, no redness, pain tenderness, swelling or infiltration.
Musculoskeletal: Mild pain on the Patient has a pain to left lower extremity.
GI: Bowels sounds was present in all four quadrants upon auscultation. Soft, non-tender, not distended, no palpable masses, normal active bowel sound, and no rebound or guarding.
GU: Patient void w/o difficult. Patient is incontinence, Pt used purewick , Patient output was 475cc and Patient intake was 236mL.
Gordon Pattern and cluster data
Elimination Pattern.
-Continent for bowel
-Incontinent for urine (pure wick)
Gordon Pattern and cluster data
Nutrition and Metabolic Pattern
No food allergies
No fluid restriction
Gordon Pattern and cluster data
Health perception and health management
-patient can make good health decisions for herself
-Risk for infection
Patient
Name: B.H
DOB: 12/22/1957
Age: 64 y/o
Preferred Language: English
Code Status: Full Code
Allergies: Iodine, Penicillin, Percocet, Oxycodone-Acetaminophen
Gordon Pattern and cluster data
Cognitive-perceptive Pattern.
-chronic pain
Patient is consent about disturbed body image due to left lower extremities no movement
NDx: Ineffective self-health management r/t age-related
malfunctions as evidence by patient age is 64, patient not being able to care for self.
Gordon Pattern and cluster data
Sleep Rest pattern:
-normal sleeping pattern
Patient takes naps throughout the shift; patient reported no difficulty sleeping patient seems relaxed.
Nsg Diagnosis: Readiness for enhanced normal sleep routines r/t natural pattern of sleep as evidence by patient taking naps, patient being relaxed, no report of difficulty falling asleep.
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Intervention and rationale
Encourage mobility
– Manage pain
Evaluation
-Progressing
– Reposition q2
Educational Nsg Dx:
Deficient knowledge related to lack of understanding to detect complications of impaired physical mobility as evidenced limited movements
Goal/outcome:
Demonstrate behaviors to improve physical mobility by doing some deep breathing every 8hr and ROM.
Psychosocial Nsg Dx:
Risk for activity intolerant as related to chronic pain
Physiological Nsg Dx
Risk for Venous Thrombosis Embolism as related to lack of adequate mobility
Goal/outcome :
Verbalizes/displays adequate comfort level or baseline comfort level
Goal/outcome
The goal is for venous thrombosis to be absence
Intervention and rationale:
Administer pain medication
Encourage patient to monitor pain and request assistance
Assess pain using appropriate pain scale
Administer analgesics base on type and severity of pain and evaluate response
Intervention and rationale:
Assist the patient to turn every 2 hours. If ambulatory, allow patient to sit up on edge of bed as tolerated.
Evaluation:
Met: Patient has developed alternative ways to deal with stress such as deep breathing technique, exercise to relieve stress.
Evaluation:
Met: Patient was able to understands and was able to state and teach back 2 complications, signs, and symptoms.
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Write about what you just did and how you thought about it. Each Gordon’s Patterns set shall be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume your instructor knows anything about your thought process, because they don’t. Show your instructor how you are thinking! How to begin…………….
On a separate page: Include ALL of the questions with the Answers of the questions:
In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped you.)
Using Gordon’s as a guide, Explain which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).
List the identified nursing diagnoses in priority order the:
“Problem” Related to “_____ “ Evidenced by “____” format.
Which nursing diagnosis is most important to address with this client? Explain how this was determined.
Which nursing diagnosis is second most important to address with this client? Explain how this was determined.
Which nursing diagnosis is least important to address with this client? Explain how this was determined.
Describe the evaluation of the client for each nursing diagnosis?
Answer questions
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On a separate page: Include ALL of the questions with the Answers of the questions:
Health Perception and Health Management Pattern: patient is to make health decision by himself. As such this Gordon’s patten is functional. This has help me to understand that this patient can make good health decision by himself, as such he does not need any one to make healthy health managements for him in other for him to live healthy.
-Nutrition and Metabolism Pattern: Patient is not on any food restriction and is not allergy to any food. This Gordon’s pattern is functional because this patient have good diet menu, no food restriction regarding his disease, no food restriction regarding religious point of vie, no food allergy, skin, scalp and nails are clean and intact. This data have help me to understand that because this patient is eating healthy that is why his skin, scalp, nails are clean, healthy and intact
-Elimination Pattern: This patient is continent both bowel and urine. This Gordon patten is functional. This data have help me know that even though patient is in palliative care he can still go to bathroom by himself.
-Cognition and Perception Pattern: patient is able to make decision about herself, alert and orientated X four as such this Gordon’s pattern is functional. This data have help me understand that because even though this patient is on palliative care, he still make good decisions concerning his health.
-Sleep and Rest Pattern: Patient sleep and rest pattern is within defined limit. This Gordon pattern functional. This will help me to know that I need to encourage patient to monitor pain and request assistance because pain can disrupt his sleep and rest pattern.
References:
Brown, D., Edwards, H., Buckley, T., & Aitken, R. L. (2020). Lewis's medical-surgical nursing: Assessment and management of clinical problems. Elsevier.
Hagler, D., Harding, M., Kwong, J., Roberts, D., & Reinisch, C. (2020). Clinical companion to medical-surgical nursing: Assessment and management of clinical problems. Elsevier.
Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care. Elsevier.
Burchum, J. R., Rosenthal, L. D., Jones, B. O., & Neumiller, J. J. (2016). Lehne's pharmacology for nursing care. Elsevier/Saunders.
Burchum, J. R., & Rosenthal, L. D. (2019). Lehne's pharmacology for nursing care. Elsevier.
Burchum, J. R., Rosenthal, L. D., Jones, B. O., & Neumiller, J. J. (2016). Lehne's pharmacology for nursing care. Elsevier/Saunders.
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,
Concept map template
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Patient
Situation: Medical Dx/pathophysiology
List doctors order
medications
Labs/xrays
Pertinent Medical History
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Assessment
Subjective /objective data
Body Systems
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Gordon Pattern and cluster data
Patient
Gordon Pattern and cluster data
Gordon Pattern and cluster data
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Intervention and rationale
Evaluation
Educational Nsg Dx
Goal/outcome
Psychosocial Nsg Dx
Physiological Nsg Dx
Goal/outcome
Goal/outcome
Intervention and rationale
Intervention and rationale
Evaluation
Evaluation
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Page 3
Write about what you just did and how you thought about it. Each Gordon’s Patterns set shall be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume your instructor knows anything about your thought process, because they don’t. Show your instructor how you are thinking! How to begin…………….
On a separate page: Include ALL of the questions with the Answers of the questions:
In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped you.)
Using Gordon’s as a guide, Explain which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).
List the identified nursing diagnoses in priority order the:
“Problem” Related to “_____ “ Evidenced by “____” format.
Which nursing diagnosis is most important to address with this client? Explain how this was determined.
Which nursing diagnosis is second most important to address with this client? Explain how this was determined.
Which nursing diagnosis is least important to address with this client? Explain how this was determined.
Describe the evaluation of the client for each nursing diagnosis?
Answer questions
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References (all in APA format)
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