Nur 105 Clinical Concept Map: Clinical Worksheet

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NUR 105 Clinical Concept Map (Clinical Worksheet page 1)
NUR 105 Clinical Area - Student use ACTUAL data findings from clinical day one... Assess the patient. Develop two physiological and one psychosocial nursing diagnosis- all 3 parts of nursing diagnosis
Actual Nursing Diagnosis/Problem:
Risk for Altered Respiratory Function r/t Decreased
Mobility 2nd TKR
Supporting Data:
 Pt. has partial mobility; experinces severe pain when moving right leg
 S.E of medication: Fluticasone, Albuterol,
Celebrex, Prilosec
 Pt. is Obese
 Nx Asthma; no exacerbations recently
 On BR today due to suspected DVT
 Pt. is diagnosed with Anemia; more suseptable to respiratory conditions.
 RBC 3.45 (3.8-10.5)
 Lung sounds clear; RR 20;
 HR-98; this was taken 5 min. after nebulizer treatment (Fluticasone).

Actual Nursing Diagnosis/Problem:
Feeling of Dread r/t suspected DVT 2nd to TKR

Reason for seeking medical attention:
Pt. fell at work injuring her right knee
Medical Diagnosis/Surgical Procedure
TKR; Nx asthma, anemia
Focused Key Assessments

Actual Nursing Diagnosis/Problem:
Constipation r/t decreased peristalsis 2nd to habitual laxative use
Supporting Data
 No bowel movement for 2 days
 Pt. stated that she regularly uses laxatives
 Prescribed analgesics (Oxycontin, Percocet)
 Lack of exercise
 Hypoactive bowel sounds
 Firm abdomen
 TKR (mobility)
 S.E of medication: Hydrodiuril & Albuterol
 Abdominal distention
Revised
 1/13
Pt. onPM
BR due to suspected DVT

Supporting Data:
 Threat of pulmonary embolysm
 Threat of Death
 Pt. became anxious upon learing of possible DVT.
 Pt. is diagnosed with multiple medical conditions  Pt. HR 98
 Pt. RR 20
 Temp. 98.6
 Pt. stated,” I don’t want to move at all until they know for sure it’s not a clot”.
 PT. showed interest in her condition and asked questions regarding DVT’s and its complications.  PT. appeared apprehensive

I don’t know how this fits:
*Heart murmur
*glaucoma
* GERD
*Hyperlipidemia
*Allergies: Peanuts/Peaches
*Adenoids removed

1

NUR 105 Clinical Concept Map (Clinical Worksheet page 2)
Actual Nursing Diagnosis/Problem:
Risk for Altered Respiratory Function r/t
Decreased Mobility 2nd TKR
Goal:
The pt. will experience adequate respiratory function as evidenced by normal respirations and normal O2 sat. readings. Nursing Interventions:
1. Assess for and report signs and symptoms of :
a. rapid, shallow respirations
b. use of accessory muscles when breathing. c. confusion; mental status
d. abnormal H&H
e. significant decrease in O2sat.
f. change in lung sounds
2. Place pt. in semi Fowler’s position
3. Encourage use of incentive spirometer.
4. Maintain adequate fluid intake
5. Educate and assist in deep breathing exercises. 6. Encourage ambulation when applicable
7. Consult with respiratory therapy
8. Asses for signs and symptoms of embolism: difficulty breathing, chest pain on inspiration, palpitations, decreased O2 sat., cyanosis, increased HR, RR & abnormally low BP.
9. Perform chest physiotherapy when applicable. 10. Promote adequate nutrition.
11. Be alert for the potential complication of cardiogenic shock or right ventricular
Revised
1/13 PM failure subsequent to the effect of PE on the cardiovascular system.

Medical Diagnosis:
TKR; Nx asthma, anemia

Actual Nursing Diagnosis/Problem:
Feeling of Dread r/t suspected DVT 2nd to TKR
Goal:
Pt. will experience a reduction in fear and anxiety as evidenced by: verbalization of feeling less anxious, stable vital signs, relaxed facial expressions and body movements and usual perceptual ability and interactions with others.
Nursing Intervention:
1. Introduce pt. to staff who will be participating in care; maintain consistency in staff when possible.
2. Keep door and curtains open as much as possible to reduce feeling of confinement.
3. Maintain a calm, supportive, confident manner when interacting with client.
4. Reinforce physician’s explanations and clarify misconceptions client has about the Dx, treatment plan, and
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