Question

Draw a concept map, identifying a minimum of four nursing diagnoses written in complete diagnostic statements.

(Nsg Dx/ rt/ aeb.) Include Actual & Risk for nursing diagnoses. Include one psychosocial nursing diagnosis.

Location: Skilled Nursing Home Care Facility 0800

Report from charge nurse:

Situation: Mrs. Morrow is an obese, 80-year-old white female who developed a venous stasis ulcer on her right medial malleolus while still living at home. She moved into our skilled nursing home care facility 3 days ago. The current plan of care is focused on promoting wound healing, improving venous return, and preventing skin breakdown.

Background: Mrs. Morrow has a past medical history of chronic obstructive pulmonary disease (COPD), chronic venous insufficiency, and deep vein thrombosis (DVT). Peripheral arterial disease is ruled out by duplex ultrasound. Her daughter had her admitted to this skilled nursing home care facility due to concern for her safety with impaired mobility, an unhealthy diet, and inability to adequately care for herself at home.

Assessment: Mrs. Morrow is alert and oriented, but sometimes forgetful of recent events. Vital signs have been within normal limits and are performed weekly. Results from yesterday's labs are in the chart. She is on a regular diet with nutritional supplement and has been eating the majority of her meals since admission. She requires assistance with positioning in bed and assistance times 1 to get out of bed to the chair or ambulate. Her gait is unsteady, and she is easily fatigued. Her Braden Scale score is 16, and her skin is intact except for the venous stasis ulcer on the right medial malleolus. She has brown hyperpigmentation on both lower legs with +2 edema. The venous stasis ulcer is covered with a hydrocolloid dressing, which is due to be changed. In preparation for her dressing change, she was medicated for pain half an hour ago.

Recommendation: You should complete a basic assessment, review the labs, perform a wound assessment and dressing change, and then reposition the patient to optimize venous return. Please provide patient education on improving venous return to prevent further stasis ulcers, and continue compression therapy with the use of elastic bandage and an antiembolism stocking.

# 2 vsim Concept Map Assignment Category Points Description Points Achieved/Comments Identification of primary reason for seeking care 5 Identifies medical/Surgical diagnosis and initials of patient. Identify patient assessment data 30 Identify pertinent patient assessment data & cluster into physiological/psychosocial systems. Data should be obtained from patient history, assessments, medications test results, lab values etc. Identification of 440 Identify a minimum of four nursing nursing diagnoses on concept map. diagnoses written in complete diagnostic statements. (Nsg Dx/ rt aeb.). Include Actual & Risk for nursing diagnoses. Include one psychosocial nursing diagnosis. Prioritize Problems 20 Number nursing diagnoses in order of (Nursing Diagnosis) Clarity of Writing 5 Use standard English grammar with no priority spelling errors, neat and organized. Total 100 Submit your reflection in a Word document to your assigned lab educator via email on canvas by the 10/17/18.

Answer 1

Identification of primary reason for seeking care

Mrs.Morrow is a 80 year old white female having the past history of Chronic Obstructive Pulmonary Disease,chronic venous insufficiency and DVT. Her present medical diagnosis is peripheral arterial disease and DVT induces venous stasis Her surgical diagnosis is Venous stasis ulcer on her right medial malleolus

Identify patient assessment data

Presently her vital signs are showing normal limit and the lab investigation there is a slight variation of HCO3,albumin,and pre-albumin level She is showing an unsteady gait and easy fatigueness after assisted ambulation.Her Braden Score is showing16,and the skin is intact except at the ulcer site.Her legs shows with +2 edema and brown hyperpigmentation of the both lower legsThe ulcer is covered with a hydrocolloid dressing In her psychological assessment showing that she is alert and oriented,but sometimes forgetful of recent events Her present medications are: *Multivitamin 1tab per oral OD *Zinc 1 tab Per oral OD *Aspirin 81mg per oral OD PRN medicationsinclude: *Albuterol inhaler 360 microgram PRN for wheezing *Acetaminophen 650mg per oral every 6 hours PRN pain Hydrocolloid dressing to right lower leg ulcer: *Clean and irrigate wound with normal saline and change the dressing for every 3 days *Antiembolismstocking to the left leg (knee-length) and elastic bandage to right leg

Identification of nursing diagnosis

*Acute pain related to ulcer *Impaired physical mobility related to altered giat and obese *Ineffective peripheral tissue perfusion related to inflammatory response *Risk for ineffective individual coping related to hospitalization at the nursing home

Prioritize nursing problem

1.Impaired physical mobility 2.Ineffective peripheral tissue perfusion 3.Fatigue 4.Acute pain 5.Risk for infection 6.Risk for ineffective individual coping 7.Risk for social isolation