Concept Map Assignment Worksheet 346: Direct Focused Care: CONCEPT MAPPING ASSIGNMENT WORKSHEET.

Concept Map Assignment Worksheet 346: Direct Focused Care: CONCEPT MAPPING ASSIGNMENT WORKSHEET. NURSING PROCESS TEMPLATE: PERFUSION Assessment(Recognizing Cues) Which patient information is relevant? What patient data is most important? Which patient information is of immediate concern? Consider signs and symptoms, lab work, patient statements, H & P, and others. Consider subjective and objective data. Full code- 62/M, African American male, presented to the ED with possible cerebral infarction. Patient presented with hypertension 167/100, pulse of 99, RR 18, O2 was 98% on room air, left sided weakness. Patient has a history of CKD and hypertension, and alcohol use. No current complaints of pain/discomfort. Patient current vital signs are BP 151/80, HR 99, O2 98% room air, RR 16. Analysis (Analyzing Cues) Which patient conditions are consistent with the cues? Do the cues support a particular patient condition? What cues are a cause for concern? What other information would help to establish the significance of a cue? Currently the patients’ conditions are consistent with a Cerebral infarction; left sided weakness and unable to lift left arm without assistance. Patient also presented with facial drooping but has been improving. Patient also presented with slurred speech upon arrival. A current cause for concern at this time is the continued elevated BP and decreased kidney function- BUN of 26, Creatine of 1.48, current K+ is within normal limits 4.0, will continue to monitor labs/ vital signs. Analysis (Prioritizing Hypotheses) What explanations are mostlikely? What is the most serious explanation? What is the priority order for safe and effective care? Priority interventions is the patients’ hypertensive episodes, if not corrected to lead to further cardiac damage and increased cranial pressure. Hypertensive medications could help lower to the patients BP. Second intervention would be providing patient with education on ways to reduce stress and increase exercise to help maintain healthy BP and build a healthier lifestyle. Third intervention would be to continue monitor patient’s BUN/CR/K+ to ensure patients maintains a healthy hydration status, and renal perfusion is at optimum working levels. ** Hypertension and DM II are the twoleading causes of kidney failure, while patients presents only with hypertension, Concept Map Assignment Worksheet 346: Direct Focused Care: CONCEPT MAPPING ASSIGNMENT WORKSHEET NIGHTINGALE COLLEGE DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET ** LATE SUBMISSION** 2 CKD can worsen with too much stress on the kidneys, as presented with the hypertensive emergency. (Giddens, 2017) Planning (Generate Solutions) What are the desirable outcomes? What interventions can achieve these outcomes? What should be avoided? (SMART Planning- specific, measurable, attainable, realistic/relevant, time-restricted- Goal setting) Desirable outcomes for this patient: Maintain systolic pressure under 140, with a goal of 125-130 systolic for healthy perfusion before discharge of patient. Education on proper diet, decreased alcohol consumption, and techniques on reducing stress for health promotion within 36 hours of hospital visit to ensure patient understands information. Monitor fluid intake and output to ensure patient is not retaining fluids twenty-four fluid monitoring. Patient to complete a swallow eval. Within 24 hours of admittance.