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Concept map template
DAMILOLA OLOYEDE

Nsg 240/245/430

Assessment

Subjective: complain of pain upon admission

objective data: leg edema, stage 2 pressure injury, right heel, right leg tear

Vital signs: BP 112/63, HR 69, RR 18, Temp 97.7. pulse ox 68, pain 8 on a scale of 0 to 10

Body Systems

Respiration; 18, clear lung sound

Cardiovascular; BP 112/63, HR 69, pulse palpation and +2 heart sound s1s2 and regular.

Integumetary; leg edema, stage 2 pressure injury right heel, right leg tear.

Urinary; condom catheter, orange clear.

Neuro/Sensory/Mental alert; alert and oriented x3

HEENT; hearing adequate, eyes PERRLA

GI; Abdomen is soft, symmetric, and non tender without distention.

Gordon Pattern and cluster data

Patient is confused and very forgetful

Relevant Gordon Pattern:

Self-Perception/Self-Concept

Definition:

A person’s behavior about self, viewpoint of abilities, body image, recognition, general sense of value, and emotional patterns style (Doenges et. Al. , 2013, p. 17).

Dysfunctional

Gordon Pattern and cluster data

Patient is stressed and in acute pain

Relevant Gordon Pattern: Coping/Stress

Definition: Universal coping style, stress tolerance, support systems, and perceive ability to control and manage issues (Doenges et. Al. , 2013, p. 17).

Dysfunctional

Gordon Pattern and cluster data

Patient has diarrhea and incontinence

Relevant Gordon Pattern: Nutrition/Metabolic

Definition: Style of food and fluid consumption, fluid and electrolyte balance, overall capacity to recover (Doenges et. Al. , 2013, p. 17

Dysfunctional

Patient

JB

90yo Male

Gordon Pattern and cluster data

Patient has a condom catheter in place

Relevant Gordon Pattern: Elimination

Definition:

Styles of excretory function (bowel, bladder, and shin) and client’s viewpoint (Doenges et. Al. , 2013, p. 17).

Dysfunctional

Gordon Pattern and cluster data

Patient cannot walk without assistance and also needs assistance to be transferred from bed to his wheelchair

Relevant Gordon Pattern: Activity/Exercise

Definition: Pattern of training ,undertaking, spare time, relaxation, and activities of daily living; factors that impede with desired or expected individual style (Doenges et. Al. , 2013, p. 17).

Dysfunctional

Medications

Escitalopram 10mg/PO/Selective Serotonin Reuptake Inhibitor SSRI. Side effect; coma, confusion, decreased urine output.

Pantoprazole/40mg/ IV/proton-pump inhibitor. Side effects joint pain, gas

Metoprolol 25mg/PO/Beta blocker. Side effect; dry mouth, depression, bloating

List doctors order

Blood work

Clear liquid diet

Condom catheter

Fall risk precaution

Labs/xrays

WBC 10.52 abnormal (high) indicating an infection

Hgb 8.6 abnormal (low)

CBC test showed Hematocrit 29.8 abnormal (low) anemia

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Pathophysiology

Abdominal pain due to Gastrointestinal bleeding. This is a common problem encountered in the emergency department and in the primary care setting. Acute or overt gastrointestinal bleeding is visible in the form of hematemesis, melena or hematochezia. Chronic or occult gastrointestinal bleeding is not apparent to the patient and usually presents as positive fecal occult blood or iron deficiency anemia.

Intervention and rational

Assess vital signs, particularly blood pressure level: Hypovolemia due to GI bleeding may lower pressure levels and put the patient at risk for hypotensive episodes that can lead to shock.

Evaluation

Goals were met

Patient report no pain upon discharge

Goal/outcome

Patient will have a blood pressure level within range

Psychosocial Nsg Dx

Ineffective health maintenance related to lack of knowledge about signs and symptoms of GI bleed stating, “visible blood in stool and rectal bleeding”.

Physiological Nsg Dx

Acute abdominal pain related to patient holding abdomen due to GI bleed as evidenced by patient stating pain level is 10 on a scale of 0-10, 10 being worse

Goal/outcome

Patient will have an absence of GI bleeding and a hemoglobin level of over 13

Goal/outcome

Pain management

Patient reports 0 level of pain on a scale of 0-10

Intervention and rational

Commence a fluid balance chart monitoring the input and output of the patient: To monitor patient’s fluid volume.

Intervention and rational

Educate the patient on how to fill out a fluid balance: To encourage the patient to drink more fluid as needed or report any changes to the nursing team

Evaluation

At the time of the evaluation, there was increase in the patients overall well being.

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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 I know anything about your thought process, because I don’t. Show me how you are thinking! How to begin…………….

 

Include ALL of the questions with the Answers of the questions:

 

  • Explain how the data clusters helped you to determine the Gordon’s Functional and Dysfunctional Patterns.
  • Using Gordon’s as a guide, which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).
  • List the identified nursing diagnoses in 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.

Select the priority physiological and psychosocial (NSG240) and educational (NSG245 and NSG430) Nursing diagnoses. Complete the Nursing process by answering the questions below and including the information in the explanation paper for each priority nursing diagnosis:

  • What is the goal for the client to show that the priority problem is reduced or resolved?
  • What would a nurse (you) need to do for the client to help the client meet the goal?
  • How would you know that the client has met the goal?

Answer questions

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References

Doenges, E. M. ,Moorhouse, F. M. (2013). Application of nursing process and nursing diagnosis

(6th ed.). DavisPlus

Kim, B. S., Li, B. T., Engel, A., Samra, J. S., Clarke, S., Norton, I. D., & Li, A. E. (2014). Diagnosis of gastrointestinal bleeding: A practical guide for clinicians. World journal of gastrointestinal pathophysiology, 5(4), 467–478. https://doi.org/10.4291/wjgp.v5.i4.467

DiGregorio AM, Alvey H. Gastrointestinal Bleeding. [Updated 2020 Aug 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537291/

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