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Essay Available:
Pages:
4 pages/β‰ˆ1100 words
Sources:
3 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 17.28
Topic:

Nursing care map Health, Medicine, Nursing Case Study

Case Study Instructions:

Summary:
Mr. Charles Lamont is a 45-year-old patient who is visiting his primary care physician for his an annual checkup. His wife is waiting for him in the lobby; she is hoping that Mr. Lamont will tell the physician about his recent bout of coughing and shortness of breath. Mr. Lamont works for a construction company as a heavy machine operator. He smokes 1½ packs of cigarettes per day. His wife has been encouraging Mr. Lamont to stop, but he has not showed any interest in quitting. Laura, the registered nurse, takes Mr. Lamont to an examination room. Laura asks him about his overall health and he tells her about a nagging cough and how he sometimes feels short of breath. He then denies any other health problems. Laura takes Mr. Lamont’s vital signs and gets the following results: blood pressure, 156/94 mm Hg; temperature, 99.8° F orally; apical pulse, 104 beats/min; respirations, 25 breaths/min and regular; and pulse oximetry, 95%.
Using the concept map template given to you in create a concept map and care plan for your patient. be sure to read the instructions file and follow the rubric in order to earn the most points.


 


Individual Care Map Evaluation Tool


Name: _______________________ Date: ___________ Patient’s initials: _______________     


 



Concept

 

 

 

 

 

 

 

(Follow instructions provided and on Moodle)

 

 

 

 

 

 

 

The  student will:


 

Maxi-mum Points/

 

 

 

 

 

 

Prepare: Written Analysis (50 pts) and Concept Map

Student points

 

 

 

 

 

Comments:

Selects relevant objective and subjective assessment data for the client situation.



5

Organizes relevant data into objective and subjective data.(2)

 

 

 

Does not organize data.(1)

 

Demonstrate appropriate use of Gordon’s Functional Patterns by organizing data into meaningful data clusters to determine priority problem  

5

Data cluster complete the support Gordon’s patterns selected (3)

Empty space

Data clusters present, < 80% of relevant data uncluded, appropriate Gordon’s pattern selected (2.5)

 Empty space

Data clusters do not support Gordon’s pattern selected. (1)

 

Plans appropriate care for client:



  • Goal statement

  • Expected outcomes


 

10

Goal statement reflects resolution or reduction of priority problem identified. (2)

Empty space

Empty space

Empty space

Client goal does not address the nursing diagnosis or Expected outcomes do not support goal achievement or are no written in SMART format. (0.5)

 

Plans appropriate care for client:



  • Nursing interventions

  • Clearly support interventions with one individualized EBP rationale per intervention and write a citation for each intervention.


 

20

3 or more nursing interventions listed address the cause of the problem and help the client achieve the goal use evidence based practice, individualized for the patient, each intervention has rationale with APA citation and reference. (20)

≤  3 nursing interventions listed address the cause of the problem and help the client achieve the goal, use evidence based practice, each intervention has rationale with APA citation and reference. (18)

≤ 3 Interventions listed do not address the cause of the problem nor help the client achieve the goal, use evidence based practice, or not relevant for the patient, each intervention has rationale with APA citation and reference. (16)

Interventions(s) do not address the cause of the problem nor assist the client to achieve the goal with evidence based practice, Or rationale inappropriate for the selected interventions, each intervention has with APA citation and reference (10)

Interventions without rationale or APA citation and reference (0)

 

Use Care Map to plan client care



 

 

 

 

 

 

 

Format relevant Care Map: Patient is represented and data cues organized into data clusters which reveal


 

10

Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc.  Indicates how each step in the nursing process affects the others, and is formatted logically. (10)


 

Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc.  Does not indicate how each step in the nursing process affects the others;  formatted logically. (9)

Does not originate from the client OR Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc.  Indicates how each step in the nursing process affects the others, and is formatted logically. (7)

Data originates from the client. Two or more of the following is not present: Relationships between concepts indicated as cause/effect, indications, examples, leading to conclusions, etc. Or Indicates how each step in the nursing process affects the others, Or is formatted logically. (5)

Does not originate from the client. Relationships between concepts are illogical or do not indicate cause/effect. Steps in nursing process not included. (2)

 

Total Points Available/ Student Points Earned:

50


 


        



 

 

 

 

 

 


 


 


Faculty signature: ______________________Student signature: __________________________

Case Study Sample Content Preview:
Nursing Care Map: An In-depth Analysis
Name:
Course
Instructor
Date:
Nursing Care Map
Assessment Subjective /objective dataBlood pressure, 156/94 mm Hg Temperature 99.8° F orallyApical pulse 104 beats/min Respirations 25 breaths/min and regular Pulse oximetry, 95%Nagging coughingShortness of breath Activity/ExerciseRespiratory rate 25 breaths/minSpO2 95%.Pulse Rate 104 beats/min Self-PerceptionAttitudes toward selfLow desire to change smoking habitHealth Management Pattern Smoking 1½ packs of cigarettes/ day45 years Coughing and shortness of breath.
Priority Nsg DImproved cardiac output Self careChange in health behavior PatientCharles Lamont
Interventions:Monitor BP, HR and RRPatient educationReduced smokingEvidence-based rationale for interventionsPatient education improves knowledge (Abu et al., 2018). Healthy lifestyle choice and change in smoking habit Goal/Expected outcomes:Blood pressure 120/80 mm HgRespirations < 25 breaths/ minPulse 60-100 bpmNo shortness of breath
EvaluationNurse intervention will reduce BP, HR and RRReduction in smokingImproved knowledge
Lamont’s Blood pressure was 156/94 mm Hg higher than the normal range at normal 120/80 mm Hg, by the temperature was normal at 99.8° F. On the other hand, the apical pulse 104 beats/min was above the normal range 60-100 bpm, and the respirations 25 breaths/min, which was also higher than the regular level 12-20 breaths/min and the pulse oximetry is 95%. Thus, Lamont suffers from tachycardia, which is a fast heart rate beat/ min and tachypnea, which is abnormally rapid breatat hing and is reflected in respirations (>20 breaths /min). Blood pressure is the measure of the force exerted against the walls of the arteries as the heart pumps blood to your body and high blood pressure (hypertension) is elevation of systolic and diastolic blood pressure 120 over 80 (120/80 mm Hg).
There is a higher risk of suffering from high blood pressure for those smoking whereby educing and abandoning smoking is necessary to prevent cardiovascular diseases in general, and high blood pressure in particular. In the health management pattern component of the Gordon health patterns there is focus n health perception and data is collected based on a person’s perceived level of health, practices to maintain the health and well-being (Abu et al., 2018). Practices such as smoking are detrimental to health, and there is a need to modify the life health style to improve health outcomes. Practicing healthy lifestyle combined with seeking medical assistance is important, but the persistent elevation of blood pressure presents challenges to intervene successfully.
In the alteration of health maintenance, is one of the factors in the subjective data is that the patient manifests a lack of knowledge regarding the impact of smoking on his health, as well as high BP and its prevention. Lamont is persistent that he will not change his lifestyle yet smoking is one of the factors that increase the risk of elevated BP and besides the smoking habits his lifestyle may elevate the blood pressure. Ideally, the care plan ought to focus on achieving the objectives that address behaviors and the risks associated with the prob...
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