Mrs. Jackson is a 76 year old woman living in a skilled nursing facility. She has Hx: CVA with left-sided weakness, incontinent of bowel and bladder, PEG tube, GERD, HTN, Dementia, and Parkinson's. Recently she was diagnosed with a UTI.
VS: T 98.6F HR 88 RR 16 BP 155/78 SPO2 98% RA
Assessment: A&Ox1. L pupil 4mm sluggish, R pupil 3mm brisk. L-sided weakness with LUE contracture Follows commands on the R side. Short term memory not intact. Slurred speech. Tremor at rest. Difficulty initiating movement. Drooling out of L side of mouth. No c/o pain. HR regular, no edema, abd soft, non-tender. PEG tube patent, insertion site clean and dry, residual 10mL. Incontinent of malodorous urine in a diaper. Hoyer lift to wheelchair.
Abnormal Labs: UA positive for WBC, bacteria, sediment, leukocyte esterase, and nitrites.
Orders:
Aspirin 325mg pFT daily
Bactrim DS 1 tab pFT BID x3 days
Benztropine 1mg pFT daily
Carbidopa/Levodopa 25/100mg pft TID
Clopidogrel 75mg pFT daily
Docusate 250mg pFT BID
Donezepil 10mg pFT qHS
Furosemide 20mg pFT BID
Lansoprazole 30mg pFT daily
Metoprolol 50mg pFT BID
Potassium chloride 10mEQ pFT daily
NPO
Probalance with Fiber at 100ml/hr via PEG tube
Water bolus 250mL q6h pFT
Directions
1. Identify abnormal findings and discuss WHY these are present.
2. Create a problem list, with ACTUAL problems. You can also list potential problems if they are directly related to a medication or abnormal lab value.
3. For each problem, list appropriate nursing interventions.
Concept Mapping Instructions
Learning objectives:
1. To create a concept map based on a patient you encountered at clinical
2. To begin creating logical connections between patient diagnoses, medications, s/sx, and lab values.
3. To identify incorrect connections between patient diagnoses, medications, s/sx, and lab values.
4. To modify concept map to reflect new connections
5. To reflect on how concept mapping has affected your learning
Directions:
1. Put your patient's initials in a BOX in the middle of the paper.
2. Put each of your patient's medical diagnoses and (including medical history) in CIRCLES around their initials. Connect the CIRCLES to the BOX with straight lines.
è Glaucoma
Atrial fibrillation ß John Doe à HTN
è CVA
3. Connect each of your patient's medications to one of their medical diagnoses. For example: metoprolol is directly connected to HTN.
John Doe à HTN à metoprolol
4. Some medications are not directly related to a specific diagnosis. If this is the case, you can add more boxes to explain why the patient is on that medication. For example, a patient may be on docusate but not have a diagnosis of constipation. They may be taking docusate to prevent constipation related to narcotic use. Narcotics are related to pain, which is related to their recent surgical procedure.
John Doe à Surgical procedure à pain à narcotic à risk for constipation à docusate
5. Connect your patient's lab values to something, either their diagnoses or medications.
John Doeà Afib à warfarin à INR 2.5
6. Connect abnormal s/sx that you observed at clinical to a diagnoses or medication or lab value.
John Doe à Afib à HR 115
è Irregular heart rate
7. Include any nursing interventions you performed for your patient.
8. Give your first draft concept map to a peer and ask them to comment on your concept map using the peer feedback form. Does it make sense? Are your connections logical? Do you need to be more clear by identifying more indirect connections?
9. Revise your concept map with the information from your peer. This will be your second draft.
10. Reflect on how creating the concept map and discussing it with your peer has affected your learning using the Reflective Summary Form.
11. Paper clip IN THIS ORDER
a. First Draft (b) Second Draft
Concept Map Reflective Summary
1. What did you learn from creating this concept map?