Concept Map Documentation Final Robles
CONCEPT MAP DOCUMENTATION
STUDENT NAME Alixis Robles
COURSE NURS400 Clinical DATE 11/2024
SECTION 1 CLIENT INFO
Patient, with the name of V.B. is a 68 year old female, is full code, on isolation contact
precautions and resides in the Intensive Care unit. Her allergies are Cephalexin and
Artorvastatin (allergies cause a full-body rash).
SECTION 2 CHIEF COMPLAINT
Chief Complaint
Respiratory failure unspecified, with Hypoxia and Hypercapnea that started in the year
of 2016.
Admitting Diagnosis
Respiratory Failure unspecified, with Hypoxia and Hypercapnea.
SECTION 3 MEDICAL BACKGROUND / PATHO
History of Present Illness (HPI)
Patient V.B. born on 11/17/1956. was admitted intially for respiratory failure,
unspecified
with hypoxia and hypercapnea. Patient is full code, advanced directive was reviewed
with patient, her daughter, and physician.
Medical History
Acute respiratory failure: A condition where you don’t have enough ocygen in the
tissues in your body (Cleveland Clinic, 2023)
Cardiomyopathy: Disease of heart muscle (Mayo Clinic, 2024)
s/p CABG X4: A surgical procedure performed to address severe coronary artery
disease (CAD) (Medtube, 2020)
Anemia: When your blood has lower than normal amount of red blood cells or
hemoglobin(Health Institutes of Health, 2022)
AKI: Sudden episode of kidney failure or damage (National Kidney Foundation, 2022)
, Surgical History
S/P coronary bipass artery, x4, s/p right AKA due to respiratory failure unspecified with
hypoxia and hypercapnea. Surgery was done to improve the patients quality of life
and to prevent acute coronary events like myocardial infarction. Recent below the
knee right amputation was performed in March of 2024 due to gangreen of the toes,
ankle, and lower calf.
Social/Psychosocial History
V.B. used to work for Disneyland, lives with her daughter whom she is very close with.
No background history was shared per the patient. Patient remains in an emotional
mood, blunted/ flat nonverbal behavior. Slowed movement. Patients daughter visits a
few times a week to spend a few hours with her mom and the patients boyfriend also
comes to visit a couple time a week to visit and it brings V.B. joy.
SECTION 4 MEDICATIONS
Insulin: 20mg daily subcutaneously. Check insulin before administration to determine
the appropriate insulin dose. Ensure the dose matches the approproate prescribed
amount. After administration, monitor blood glucose levels, observe for hypoglycemia
(tremors, shakiness, confusion) and check the injection site for irritation. Confirm
allergies with patient.
Midodrine: Check the patient blood pressure (laying, sitting, standing) before
administration, check heart rate because medication can cause bradycardia. Confirm
allergies with patient. After administration, regularly monitor BP and HR, and observe
for signs of hypertension. Educate patient about the timing of doses abd ensure
adequate hydration.
Acetaminophen: Before administration, confirm the reason for the medication, for pain
or fever relief. Verify appropriate dosage, assess liver function since the liver
metabolizes Acetaminophen. Lastly, confirm if the patient has any allergies.
SECTION 5 LABS & DIAGNOSTIC TESTS
CONCEPT MAP DOCUMENTATION
STUDENT NAME Alixis Robles
COURSE NURS400 Clinical DATE 11/2024
SECTION 1 CLIENT INFO
Patient, with the name of V.B. is a 68 year old female, is full code, on isolation contact
precautions and resides in the Intensive Care unit. Her allergies are Cephalexin and
Artorvastatin (allergies cause a full-body rash).
SECTION 2 CHIEF COMPLAINT
Chief Complaint
Respiratory failure unspecified, with Hypoxia and Hypercapnea that started in the year
of 2016.
Admitting Diagnosis
Respiratory Failure unspecified, with Hypoxia and Hypercapnea.
SECTION 3 MEDICAL BACKGROUND / PATHO
History of Present Illness (HPI)
Patient V.B. born on 11/17/1956. was admitted intially for respiratory failure,
unspecified
with hypoxia and hypercapnea. Patient is full code, advanced directive was reviewed
with patient, her daughter, and physician.
Medical History
Acute respiratory failure: A condition where you don’t have enough ocygen in the
tissues in your body (Cleveland Clinic, 2023)
Cardiomyopathy: Disease of heart muscle (Mayo Clinic, 2024)
s/p CABG X4: A surgical procedure performed to address severe coronary artery
disease (CAD) (Medtube, 2020)
Anemia: When your blood has lower than normal amount of red blood cells or
hemoglobin(Health Institutes of Health, 2022)
AKI: Sudden episode of kidney failure or damage (National Kidney Foundation, 2022)
, Surgical History
S/P coronary bipass artery, x4, s/p right AKA due to respiratory failure unspecified with
hypoxia and hypercapnea. Surgery was done to improve the patients quality of life
and to prevent acute coronary events like myocardial infarction. Recent below the
knee right amputation was performed in March of 2024 due to gangreen of the toes,
ankle, and lower calf.
Social/Psychosocial History
V.B. used to work for Disneyland, lives with her daughter whom she is very close with.
No background history was shared per the patient. Patient remains in an emotional
mood, blunted/ flat nonverbal behavior. Slowed movement. Patients daughter visits a
few times a week to spend a few hours with her mom and the patients boyfriend also
comes to visit a couple time a week to visit and it brings V.B. joy.
SECTION 4 MEDICATIONS
Insulin: 20mg daily subcutaneously. Check insulin before administration to determine
the appropriate insulin dose. Ensure the dose matches the approproate prescribed
amount. After administration, monitor blood glucose levels, observe for hypoglycemia
(tremors, shakiness, confusion) and check the injection site for irritation. Confirm
allergies with patient.
Midodrine: Check the patient blood pressure (laying, sitting, standing) before
administration, check heart rate because medication can cause bradycardia. Confirm
allergies with patient. After administration, regularly monitor BP and HR, and observe
for signs of hypertension. Educate patient about the timing of doses abd ensure
adequate hydration.
Acetaminophen: Before administration, confirm the reason for the medication, for pain
or fever relief. Verify appropriate dosage, assess liver function since the liver
metabolizes Acetaminophen. Lastly, confirm if the patient has any allergies.
SECTION 5 LABS & DIAGNOSTIC TESTS
