Acute Care Patient Paper and PPT
Acute Care Patient Paper and PPT
This assignment has a total point value of 100 and is worth 15% of your Assignment grade.
Submit project on a PowerPoint. Students will present their patient on BB Collaborative
Select a client for whom you have provided care to complete your project. The client should have both primary and secondary diagnoses to qualify for the study. Present the client’s profile including all pertinent demographic data. Identify and prioritize 3 nursing diagnoses.
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Describe the relationship among the primary and secondary diagnoses.
Identify the five stressors: physiological, psychological, socioeconomic, cultural and spiritual.
Construct a power point presentation to display all the medical diagnoses. This does not need to be an excessive PowerPoint, but you should be able to explain yourself well
Display all nursing diagnoses in boxes around the circle, using arrows to show relationship among the diagnoses. Be sure to include relevant data to support the relationship among the primary and secondary diagnoses. This should include assessment data, lab data, and pharmacological agents. Describe the pathophysiology of each diagnosis.
The map must be clear and concise.
The update of the assignment. This does not need to be a concept map. Please put all pertinent information on the assignment. As stated below. The presentation should show your professionalism and knowledge regarding the management of your patient.
Remember that the patient is an acute care patient. No risk for fall or Acute pain nursing diagnosis. Let the assessment, lab and diagnostic information guide your plan.
This assignment has a total point value of 100 and is worth 15 % of your grade.
Submit this grading tool with your Concept Map Project
Criteria Possible Points Your Grade
Diagnosis
Nursing and Medical Diagnoses 10 points __________
Identify primary diagnosis and at least
two secondary medical diagnoses.
Identify and prioritize 3 nursing diagnoses
Data to Support Diagnoses 5 points __________
Objective and subjective data that
supports the nursing diagnoses chosen.
(health assessment data)
Relationship between diagnoses 5 points __________
Identify the relationship among the
primary and secondary medical diagnoses
Variables
Identify stressors for each of the following variables
Physiological 5 points __________
Psychological 5 points __________
Socioeconomic 5 points __________
Cultural 5 points __________
Spiritual 5 points __________
Client
Patient Profile 5 points __________
List all pertinent demographic data
including age and sex
Nursing
Nursing Interventions with Rationale 10 points __________
Identify 5 interventions for each nursing
diagnosis. Be sure to support your
rationale with references
(text & journal articles).
Pharmacology 10 points __________
Identify all pharmacological agents
involved in the care of the client.
Pathophysiology 10 points __________
Identify the physiology of primary and
secondary diagnosis. Make sure that you
explain the disease process and how the
nursing diagnosis relates.
CONCEPT MAP 20 points __________
Effective communication
Communicates medical diagnosis
Power point should contain all information
Clearly explains patient concerns and management
Challenges peers (ask questions)
Professional language utilized
If you chose you may follow the information as presented below.
Display all medical diagnoses in a circle at the center of your map.
Display all nursing diagnoses in boxes around the circle.
Be sure to include relevant data to support the relationship
among the primary and secondary diagnoses.
This should include lab data, pharmacology, and assessment data.
Use arrows to show relationships among the diagnosis
If you are missing pertinent labs of diagnostic studies, you should discuss expected
studies which are needed.
| 78 YO African-American Female Religion: Baptist Full Code
Presented via ambulance from a nursing home where he is a long term resident. He had altered mental status. 2 days ago he had a fall
He has past medical history of Dementia, Diabetes Type 2, Depression, HTN, CAD,
Home Meds: Enelapril, Lopressor, Cardizem, glipizide, Senna, Lovastatin. Gabapentin, Calcitrate with D, tylenol
Physical Exam: Neuro: Alert, confused, clear speech. Able to follow command CVS: heart s1 s2 no murmur, HR 110 regular BP 120/69 cap refill > 2 seconds, no peripheral Edema. Saline lock line left forearm Resp: lungs diminished throughout. Cough productive, unlabored resp, RR 24. Pulse oximeter 93% on oxygen 2l/min by nasal cannula GI: Bowel sounds-normoactive , Abd soft, non-tender. Poor oral intake, bowel incontinent GU: urinary incontinence Muscskel: non-ambulatory, requires one assist to chair Skin: No bruises, rashes. No skin breakdown
Admitting diagnosis: Pneumonia, Acute Kidney Injury, encephalopathy, symptomatic,
Hospital Medications: Heparin 5000 U Q12h SQ, Zosyn , Kay Exalate,
Diagnostic Test: Chest Xray: bilateral pneumonia Head CT- no acute changes, atrophy consistent with aging, Chest CT- Hilar mass with lymphadenopathy EKG- no changes BMP: Glucose 180, Na 141, Cl 110, K 6.2, BUN 30, Creat 2.7, Ca 16.9 CBC: WBC 26.1 Hgb 11.2, Hct 33.3, Plt 150, HCO3 23 |