Concept Map
7 Systems
Skin
Respiratory
Musculoskeletal
Nursing Diagnostics
Female
91 years old
Nursing home patient
Type 2 Diabetes
AFib
Etiology: many factors can cause a person to go into afib, including physical activity that strains the heart, blockage in a vessel of the heart, heart attacks or heart disease, and abnormal heart formation. (Nayak et al., 2020)
Widow
Risk Factors: Can occur from a combination of factors such as genetics, inactivity, poor diet, and obesity. (Norris et al., 2020 p. 871)
Pathophysiology: Type 2 diabetes occurs when insulin can be high, low, or normal. However, there is an insulin resistance, meaning the ability of insulin act effectively on target issues, especially muscle, liver, and fat is decreased. (Norris et al., 2020)
Pathophysiology: During atrial fibrillation, the heart's upper chambers beat chaotically and irregularly - out of sync with the lower chambers of the heart. For many people, afib may have no symptoms. However, afib may cause a fast, pounding heartbeat, shortness of breath or weakness. (Norris et al., 2020)
Risk Factors: increased age, family history, damaged heart structure, HTN, heart attacks, CAD, abnormal heart valves, stress, viral infections. (Norris et al., 2020)
Symptoms: frequent urination, increased thirst, fatigue, tiredness, sudden weight loss, slow healing cuts or wounds, blurred vision. (Norris et al., 2020 p. 872)
Warm, dry, color normal for race and age
No bruises, rashes, lesions
Good skin turgor
Mild weakness
Normal bilateral appearance
Ambulates with supervision
Cardiac
Normal respiratory rate and effort, frequent/productive cough
18 breaths per min
96% O2 saturation on room air
S1S2
Regular rate and rhythm
No edema noted, peripheral pulses 2+
Neuro
Alert and oriented to person, place, time, situation
Occassionally confused, extremelly hard of hearing. Hearing aids used
Abdominal/GI
Genitourinary
Continent w/ occasional incontinence
No pain, normal urine color
Symptoms: heart palpitations, SOB, weakness, fatigue, reduced ability to be physically active, light deadness, dizziness, confusion, chest pain. (Norris et al., 2020)
risk for impaired physical mobility
risk for unstable blood glucose level
risk for dysfunctional gastrointestinal motility
Diagnostics
BP: 149/67mmHg
Temp: 97.5 °F
Pulse: 80 bpm
Resp: 18 bpm
O2: 96%
Weight: 204.2 lbs
Bowel sounds active
Soft, nontender, nonobese, not distended
Toilets self, continent
Cooperative and normal speech
Client will have formed stools throughout nursing home stay.
Nurse will assist with daily activities and ambulation to promote gastrointestinal motility and prevent bowel stasis. (Ackley et al., 2017 p. 380)
Nurse will review and administer appropriate gastrointestinal medication to prevent diarrhea. (Ackley et al., 2017 p. 380)
Nurse will monitor for abdominal distension and presence of abdominal pain. (Ackley et al., 2017 p. 380)
Client will maintain stable blood glucose level in the 70-130 mg/dL range throughout nursing home stay.
Nurse will administer prescribed insulin and diabetes management medication as prescribed. (Ackley et al., 2017 p. 415)
Client will meet mutually defined goals of increased ambulation with increased verbal confidence by end of the year.
Nurse will provide and teach passive and active range of motion exercise. (Ackley et al., 2017 p. 589)
Nurse will medicate and treat pain as appropriate for physical mobility. (Ackley et al., 2017 p. 589)
Nurse will consult with physical and occupational therapy. (Ackley et al., 2017 p. 589)
Nurse will assess patient daily for signs of hypo/hyperglycemi. (Ackley et al., 2017 p.415)
Nurse will obtain and evaluate blood sugar levels as prescribed and on PRN basis. (Ackley et al., 2017 p.415)
Hypertension
acute confusion
Client will be oriented to time, place, and person throughout the day.
Nurse will orient client to person, place, time, and situation throughout the day to avoid confusion. (Ackley et al., 2017 p.237)
Nurse will remind staff and visitors to enunciate words when speaking to client to avoid confusion. (Ackley et al., 2017 p.148)
Nurse will ensure client is wearing hearing aids correctly throughout the day. (Ackley et al., 2017 p.237)
Medications
acetaminophen 325mg PO q4h PRN
losartan potassium 50mg PO daily
Pathophysiology: High blood pressure is an increase of forces and pressure on the arteries. This force presses against the arterial walls and creates extra work for the heath to pump blood throughout the body. High blood pressure is recognized with a measurement of 130/80 or higher. (Harrison et al., 2021)
Symptoms: headache, shortness of breath, poor cardiac output and function, angina, heart attack, and vision changes. (Norris et al., 2020)
Risk Factors: poor diet, obesity, alcohol, smoking, age, inactivity, kidney disease, pregnancy. (Norris et al., 2020)
Etiology: may not result from any medical condition. It is caused by environmental and personal conditions, such as obesity, sedentarism and unhealthy food (fatty or with high amount of salt). Secondary causes may be evaluated in extremes of age or according to the clinical case presented. (Norris et al., 2020)
History of UTI
miralax 17gm oral packet daily
buspirone HCl 15mg PO BID
sertraline HCl 100mg PO HS daily
metformin HCl 1000mg PO BID
levothyroxine sodium 100mcg PO daily
oxybutynin chloride ER 15mg PO daily
preservision 2 capsule PO daily
Glutose 15 gel 40% 37.5 gm Q10min PRN BS
pain rating: 0 (scale of 0-10)
DNR
BS: 130 mg/dL
no other lab values available in chart
glipizide 5mg PO two tabs BID
furosemide 20mg PO daily
apixaban 5mg PO BID
amlodipine besylate 5mg PO HS daily
accuchecks weekly (every thursday morning), PRN
PRIMARY
SECONDARY
SECONDARY
PHQ-9 score: 4.0 (minimal depression)
allergies: penicillin, codeine, naproxen
assistive devices: wheelchair, dentures, glasses, hearing aids
Etiology: Genetics, inactivity, poor diet, and obesity can all cause type two diabetes. (Norris et al., 2020 p. 871)