PATIENT FOR Concept mapHISTORY OF PRESENT PROBLEM:Patient is Joan Walker; she is 84 years old. She h

PATIENT FOR Concept mapHISTORY OF PRESENT PROBLEM:Patient is Joan Walker; she is 84 years old. She has had a productive cough which is green in color for the past 4 days. Her PCP (primary care provider) started her on Prednisone 40 mg daily and Azithromycin (Zithromax) 250 mg PO for 5 days which she started 3 days ago. She has had intermittent chills, a fever last night of 102F/38.9C and has increased shortness of breath especially in the evening and during the night. She is using her albuterol inhaler about every 1-2 hours which does not seem to be working. She called 911 and is now in your ER and you are the nurse responsible for her care.PERSONAL/SOCIAL HISTORY:Joan is a widow for the past 6 months, after being married for 64 years and is currently living in a SNF (skilled nursing facility). Taught as an elementary school teacher for over 30 years in the local community. She is active in her church and called her pastor who can with her to the ER. You walked in as the pastor asked Joan if she would like to pray. Joan replied to the pastor “yes please I feel that this may be the beginning of the end for me” Current vital signs T: 103.2F/39.6, P 110 regular, R 30 labored and using accessory muscles, BP 178/96, O2 sat 86% on 6 liters of oxygen via nasal cannula, P-Q-R-S-T Pain Assessment Provoking: deep and shallow breathing, Quality: ache, Radiation: generalized pain over right side of chest no radiation, Severity: 3/10, Timing: Intermittent last a few secondsCURRENT ASSESSMENT:General Appearance: appears anxious and in distress, barrel chest observedRespiratory: Dyspnea with use of accessory muscles, breath sounds very diminished bilaterally anterior and posterior with scattered expiratory wheezingCardiac: Pale hot and dry, no edema, heart sounds regular S1 S2 pulse strong equal with palpation at radial/pedal/post-tibial landmarksNeuro: Alert and orientated to person, place, time, and situation (x4)GI: Abdomen soft nontender bowel sounds audible per auscultation in all 4 quadrantsGU: Voiding without difficulty, urine clearSkin: intact turgor elastic and no tenting visibleFluid and Electrolytes/Lab/ Diagnostic resultsChest x-ray: left lower lobe infiltrate with hypoventilation present in both lung fields Lab: WBC (4.5-11.0) hers: current is 14.5 prior was 8.2Hgb (12-16g/dL) current 13.3 prior was 12.8Platelets (150-450×103/ul) current 217 prior was 298Neutrophil % (42-72) current 92 prior was 75Band for (3-5%) current 5 prior was 1Here is more lab data: Basic Metabolic Pane. (BMP):Sodium (135-145 mEq/L) current 138 prior 142Potassium (3.5-mEq/L5) current 3.9 prior 3.8CO2 (Bicarb) (21-31mmol/L) current 35 prior 31Glucose (70-110 mg/dL) current 112 prior 102BUN (7-25 mg/dL) current 32 prior 28Creatinine (0.6-1.2) current 1.2 prior 1.0Lactate (0.5-2.2 mmol/L) current 3.2 prior NA ARTERIAL BLOOD GAS (ABG): pH (7.35-7.45) current 7.25pCO2 (35-45) current 68pO2 (80-100) current 52HCO3 (bicarb) (18-26) current 36O2 sat (>92%) current 84%What is the ABG interpretation?HERE IS THE PATIENT’S MEDICATION Lorazepam 2.5 mg every 6 hours as needed for anxietyAtorvastatin 600 mg twice a dayEnalapril 10 mg dailyAlbuterol MDI 2 puffs every 4 hours PRNSalmeterol/fluticasone Diskus (Advair) 1 puff every 12 hoursTriamterene-HCTA (Dyazide) 1 tablet dailyPlease help me with the concept map based on the complete physical assessment performed while providing care using the provided power point template. Components of the concept mapIndividual’s information (10 points/10%)AgeMedical diagnosisBrief review of underlying pathophysiology *List what functional changes are happening                              *List process that initiated and maintained disorder or diseaseAssessment Data (15 points; 15%)Include all assessment data, not simply information that supports the selected nursing diagnosesInspectPalpationPercussionAuscultateNeurological ExamNursing Diagnoses (15 points/ 15%)Select three nursing diagnoses to addressesOne must be an actual problemOne must address a psychosocial needThe final must be a high priority for the individualLinkages Within and Between Diagnoses (5 points/5%)Concept map demonstrates relationship within and between the nursing diagnoses.Planning (15 points/15%)Prioritize diagnoses to reflect needs of the individualSet realistic outcome measurementAt least two (2) scholarly, primary sources from the last 5 years, excluding the textbook, are providedImplementation (15 points/15%)Interventions are individualized for patient-provide rationaleInterventions support achievement of selected outcome measurements-provide rationaleEvaluation of Outcomes (5 points/15%)Determine if outcomes were met.Provide evidence that supports that determination.Describe what changes, if any, are needed to promote expected outcomes in the futureSafety-Communication-Infection Control 16 points/16%)specific elements of communication used when providing care,safety concerns related to the individual for whom you cared, andinfection control practices followed while caring for this patient.Medical DiagnosesPathophysiology reviewAssessment Data … Show more… Show moreMedical Diagnoses Pathophysiologyreview Assessment Data Patient initials:Student: Age: Male I Fema… Show more… Show more  Health Science Science Nursing NURS 111 Share QuestionEmailCopy link Comments (0)

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