Purpose: Students will develop a plan of care concept map using assessment data collected from the care they provided and a review of the patient’s chart. The concept map will incorporate priority-nursing diagnoses, interventions, and predicted outcomes.
You must get instructor approval for which patient you would like to use for your concept map.
Assignment Objectives:
• Create a concept map diagram that is individualized for your patient
• Develop a priority list of problems from the assessment data
• Categorize & analyze the data/findings into clusters
• Prioritize the nursing diagnoses and link the assessment data
• Develop nursing interventions and outcomes for each priority nursing diagnosis
• Evaluate the patient’s response to the nursing care
Use the Concept Map Template Use intext citation and a separate reference page.
Information about the patient
57-year-old male, named Patrick Carnes admitted in the hospital for AFib and rapid ventricular response. He is diagnosed with NSTEMI.
Diet- Cardiac diet- 2g sodium, low fat
Allergies- No known allergies
Medical History: Lung disease, Leukocytosis, Morbid obesity, Lactic acidosis, Hyponatremia
Daily Weight: 456lb 5.6 oz
Shift vitals (latest): Temp- 36, BP-108/78, Respiration- 20, HR- 103, Pulse- 103, 0xygen saturation- 93.
Neurological- Orientedx4
Renal/ Urinary- Continent urine status
Respiratory- regular, dyspnea with exertion
Cardiovascular: Irregular cardiac rate, AFib
Wound: none
Skin- dry and intacted
Fall risk/safety: Yes, Fall risk
Psychosocial: WDL
Pain: no pain
Musculoskeletal: Edema 2+ in both RLE & LLE
IV lines: Peripheral IV in left hand and left forearm.
Abnormal Labs:
Sodium 132
Glucose 114
Calcium 8.1
WBC 13.24
APTT- 61.3
INR 1.81
Med Orders:
• Albuterol
• Aspirin 400 mg tab q8
• Digoxin (IV) 250 mcg every 12 hr.
• Diltiazem 125 mg in dextrose 5% 125 ml infusion.
Start at 5 mg/hr. and titrate by 2.5 mg/hr. every 15 min (max 15 mg/hr.)
• Finasteride 5 mg oral daily
• Lidocaine 5% patch
• Metoprolol
• Pantoprazole 40 mg oral daily
• Ibuprofen
• Furosemide
• Heparin IV 15000 units/ml