NSG 110 Health Management and Nursing Diagnostic Presentation

Concept map template Name Evelyne Belile Class: NSG 110 Due Date: 11/16/20 Patient’s Initials: J. S Nursing 110 Step 1: Complete the chart using the patient assigned to you. You may want to refer to the Physical Assessment Chapter in the Tres & Wilkinson text for assistance. Do not leave any box blank, use “Not Applicable” if there is absolutely nothing that you can identify for the box. Body Systems Subjective Data Objective Data Neurologic She know her mother None HEENT (Head, Eyes, Ears, Nose, Throat) No problem swallowing, because ,she said she ate a whole plate of food None Integument None Fine suture, at the RLQ 2cm, she had 5 sutures. No redness at the site, no drainage too Musculoskeletal ‘’ I can not walk today’’ ‘’Hurt when I try to turn over‘’ She was so reluctant to turn She was grimacing Cardiovascular None Elevated blood pressure 138/92 Heart Rate 96 which was regular Respiratory None 98%,oxygen saturated Temp 99F GI Denied nausea and vomiting Stated pain at 9/10 at the RLQ Pain at 9/10 at the RLQ Bowel sound present x4 RLQ Abdomen is firm when palp GU None None Emotional/Social/Spiritual ‘’Maawaa’’ she called her mother Rolling her eyes, when her mum tried to comfort her Reproductive None None Step 2: Place the subjective and objective data under the appropriate Gordon’s Functional Pattern. Note: Findings may repeat in multiple boxes this is the process of forming “data clusters”. Not every box will have data – type not applicable under the data cluster, but give a definition. Expand and rearrange the boxes as needed. Clustered Data (all relevant) Ate 100% of her meal It was a clear liquid diet She had 5 sutures intact No redness, no drainage, and no swelling at the site Relevant Gordon Pattern: Nutrition/Metabolic Definition: It describe the pattern of food intake In relationship to metabolic need and pattern indicators of local nutrient ss Clustered Data (all relevant) Clustered Data (all relevant) Reluctant to move due to pain She stated ‘’I can walk this morning. Relevant Gordon Pattern: Activity/Exercise Definition: Pattern of exercise, leisure and, recreation Restless and grimacing Roll her eyes when her mother tried to comfort her Pain at 9/10 Relevant Gordon Pattern: Self-Perception/Self-Concept Definition: Individual attitudes about ones self, body image, identity and emotional pattern Clustered Data (all relevant) She rat her pain at 9/10 Rolling her eyes when her mother tried to comfort her Relevant Gordon Pattern: Coping/Stress Definition: It describes general coping, stress tolerance, support systems and the ability to control and manage situations Patient Name: Jackie Shawn Age 17 yrs.: Gender: Female Chief Complaint: Pain at the Right Lower Quadrant And Nausea Clustered Data (all relevant) NONE Relevant Gordon Pattern: Health Perception/Health Management Definition: Describe the patient pattern of perception of general health status and well being, Adherence to preventive health practices Clustered Data (all relevant) Denies nausea and vomiting Bowel sound x4 quadrant Abdomen is firm when palped Passing gas Relevant Gordon Pattern: Elimination Definition: It describe the pattern of excretory function( bowel, bladder, and the skin) Clustered Data (all relevant) NONE Relevant Gordon Pattern: Value/Belief Definition: There are values, goals or beliefs that guide choices or decisions Clustered Data (all relevant) Rolling her eyes when her mother tried to comfort her Relevant Gordon Pattern: Sleep/Rest Definition: Is a pattern of sleep and rest, relaxation period during 24hours day as well as quality and quantity. Clustered Data (all relevant) Pain at 9/10 She also stated she has sharp constant pain Then she restless and grimacing Relevant Gordon Pattern: Cognitive/Perception Definition: It describe the sensory modes, which are vision,hearing,taste,touch,smell, pain perception, cognitive functional abilities Clustered Data (all relevant) Clustered Data (all relevant) Mother was at her bed side She stated Maah,when her mother rub her back NONE Relevant Gordon Pattern: Role/Relationship Definition: Describes the pattern of the role of engagements and close relationship Relevant Gordon Pattern: Sexuality/Reproductive Definition: When a patient perceived satisfaction or dissatisfaction with sexuality Step 3: Type in the Data Clusters. Identify the Gordon’s Pattern and functionality; Analyze the data cluster to determine the problem. Identify the appropriate Nursing Diagnostic Label (nursing diagnosis). Complete the remaining sections. Include arrows showing how each data cluster/problem influences others on the care map. . Add, Expand, or Rearrange the boxes as needed. Clustered Data (all relevant) Patient stated pain rate at 9/10 Sharp constant pain She was restless She stated ‘’ I cant walk this morning She was grimacing Relevant Gordon Pattern (name, functional or dysfunctional): Associated Nursing diagnostic label: Acute Pain due to disrupted tissues during the surgery evidence by the patient stated ‘’I can walk this morning’’ And also her pain rate which was 9/10 Clustered Data (all relevant) Patient stated ‘’I can walk this morning She was grimacing and restless Relevant Gordon Pattern (name, functional or dysfunctional): Associated Nursing diagnostic label: Impaired physical mobility ,in related to the pain of 9/10 in evidence by patient saying ‘’’I can walk this morning’’ In your own words, based on the data cues, what is the most important (priority) problem? Acute Pain Clustered Data (all relevant) Passing gas Firm abdomen when palped Denied nausea and vomiting Clustered Data (all relevant) Firm abdomen when palpated Passing gas Clustered Data (all relevant) Relevant Gordon Pattern (name, functional or dysfunctional): Relevant Gordon Pattern (name, functional or dysfunctional): Relevant Gordon Pattern (name, functional or dysfunctional): Associated Nursing diagnostic label: Risk for infection related to invasive procedure, evidence to the firm abdomen when palpated Associated Nursing diagnostic label: Risk for falling in related to The restless, grimacing, And when she stated ‘’I cant walk this morning’’ Associated Nursing diagnostic label: Risk of constipation in related to the passing gas, denied nausea and vomiting Abdomen firm when palped evidence by the patient passing gas and denied nausea and vomiting. Patient Name: J.S Age 17 Yrs. : Gender: Female Situation: Acute Pain Nausea Priority Nursing Diagnostic Statement: Control of Pain Diagnostic Label Acute Pain Related to Disruption of tissue due to the surgery Evidence To the client stating her rate of pain at 9/10 Patient’ ’I can not walk’’ Goal: List and prioritize all Nursing Diagnostic Statements (3 part or 2 part) based on data clusters above (at least 3): 1. Acute Pain –In related to the surgery 2. Impaired Mobility- In related to the pain and how restless and grimacing the patient is. 3. Risk of constipation – In related to passing gas and denied nausea and vomiting 2-3 SMART outcomes: 1.Pain will seized by 2 weeks 2.Monitor vital signs ,so that it could be stable 3, Encourage rest and sleep References Gordon, M. Nursing Diagnosis: Process and application, Third Edition.St.Louis: Mosby, 1994 Vera, M.,& Bsn. (2019, April 09). 13 Surgery (Perioperative Client) Nursing Care Plans. Retrieved from https://nurselabs.com/13-surgery-perioperative-client-nursing-care-plans Application Of Nursing Process and Nursing Diagnosis An Interactive Text for Diagnostic Reasoning, 6 Edition by Marilynn E. Doenges Mary Frances Moorhouse. …