Concept Map Documentation- Draft
CONCEPT MAP DOCUMENTATION
STUDENT NAME Lauren Frank
COURSE Nurs320 DATE 12/14/24
SECTION 1 CLIENT INFO
Patient is a 54 year old hispanic female, Spanish speaking only, admitted to ICU/TELE
unit. Patient is not on any isolation precautions, full code status and no known
allergies.
SECTION 2 CHIEF COMPLAINT
Chief Complaint
Patient complained of left leg pain, due to missing the last step on the stairs 6 days
ago. Patient states that her left knee has been swollen, no open injuries noted.
Admitting Diagnosis
Fracture of the left tibial plateau; Osteopenia.
SECTION 3 MEDICAL BACKGROUND / PATHO
History of Present Illness (HPI)
Patient states that she has been in pain for the past 6 days. Patient describes a
stabbing pain with movement of her left leg.
Medical History
End-Stage Renal Disease (Hemodialysis TTS)
Diabetes Mellitus II
Hypertension
Hyperlipidemia
Diabetic Polyneuropathy
Diabetic cataract of the right eye
Chronic Anemia
, Surgical History
No significant surgical history.
Patient is on the transplant list due to Chronic Kidney Disease.
Social/Psychosocial History
Patient lives with her husband in Stanton where they rent a room. Patient is insured
with healthnet and receives hemodialysis 3x per week on Tuesday, Thursday and
Saturday. She receives transportation assistance to and from her appointments.
Patient is retired, has limited familty support due to her children being in Mexico. Her
husband had limited mobility ue to a swollen leg. Patient denies any history of
smorking, or any use of illicit drugs.
SECTION 4 MEDICATIONS
Calcium Acetate 667mg TID for stomach acid
Insulin-Lispro 1-6 Units (low dose) QID for Diabetes Mellitus II
Atenolol 25mg Q Daily for Hypertension
Amlodipine 5mg Q Daily for Hypertension
Tylenol 650mg Q 4 hours PRN for Pain (1-3 on pain scale)
Atorvastatin 40mg QHS Antihyperlipidemia
Clonidine 0.1mg Q 6 hours PRN for Hypertension
SECTION 5 LABS & DIAGNOSTIC TESTS
CONCEPT MAP DOCUMENTATION
STUDENT NAME Lauren Frank
COURSE Nurs320 DATE 12/14/24
SECTION 1 CLIENT INFO
Patient is a 54 year old hispanic female, Spanish speaking only, admitted to ICU/TELE
unit. Patient is not on any isolation precautions, full code status and no known
allergies.
SECTION 2 CHIEF COMPLAINT
Chief Complaint
Patient complained of left leg pain, due to missing the last step on the stairs 6 days
ago. Patient states that her left knee has been swollen, no open injuries noted.
Admitting Diagnosis
Fracture of the left tibial plateau; Osteopenia.
SECTION 3 MEDICAL BACKGROUND / PATHO
History of Present Illness (HPI)
Patient states that she has been in pain for the past 6 days. Patient describes a
stabbing pain with movement of her left leg.
Medical History
End-Stage Renal Disease (Hemodialysis TTS)
Diabetes Mellitus II
Hypertension
Hyperlipidemia
Diabetic Polyneuropathy
Diabetic cataract of the right eye
Chronic Anemia
, Surgical History
No significant surgical history.
Patient is on the transplant list due to Chronic Kidney Disease.
Social/Psychosocial History
Patient lives with her husband in Stanton where they rent a room. Patient is insured
with healthnet and receives hemodialysis 3x per week on Tuesday, Thursday and
Saturday. She receives transportation assistance to and from her appointments.
Patient is retired, has limited familty support due to her children being in Mexico. Her
husband had limited mobility ue to a swollen leg. Patient denies any history of
smorking, or any use of illicit drugs.
SECTION 4 MEDICATIONS
Calcium Acetate 667mg TID for stomach acid
Insulin-Lispro 1-6 Units (low dose) QID for Diabetes Mellitus II
Atenolol 25mg Q Daily for Hypertension
Amlodipine 5mg Q Daily for Hypertension
Tylenol 650mg Q 4 hours PRN for Pain (1-3 on pain scale)
Atorvastatin 40mg QHS Antihyperlipidemia
Clonidine 0.1mg Q 6 hours PRN for Hypertension
SECTION 5 LABS & DIAGNOSTIC TESTS
