Nursing Concept Care Map Assignment
● Patient Name: P.S.
● Age: 56-years
● Gender: Male
● Height: 5’ 10”
● Weight: 150 lbs, 68 kg
● Religion: Catholic
● Occupation: Patient works at a Pharmaceutical company in the Manufacturing department.
a) Current treatment: Patient is currently treated for irregular heart rate and rhythm with high blood pressure and decreased peripheral pulse. He also has a history of Myocardial Infarction (MI) which was diagnosed at the age of 51.
b) Current medications: Prescription Amlodipine Besylate 5mg P.O. q.d. (once a day)
Aspirin 150mg P.O. q.d. (once a day)
2. Family History
● Brother was diagnosed with Asthma at the age 45, 1972.
● Grandfather was diagnosed with lung cancer at age 60.
● Father and mother has a clean health history.
● Siblings, Aunt and Uncle has a clean health history.
3. Current lifestyle practices
● Diet: Eats healthy food as recent. But eats fried food once or twice a month.
● Activity: Exercise once a week or once every two weeks for 1 hour.
● Sleep Patterns: 5-6 hours per night. Has orthopnea (needs to sleep in upright position with 3 pillows)
● Elimination patterns: Urinates 5-6x a day and bowel elimination 1-2x a day. Patient stated, “Usually has bowel movements every other day.”
● Alcohol consumption: None
● Smoking: 1 pack in two weeks.
● Recreational drugs: None
● Annual physical examination: Patient’s annual check ups are up-to-date with the most recent Physical exam a week ago. Has bilateral +2 pedal edema. Decreased peripheral pulse (Radial pulse +1 bilaterally; pedal pulse +1 bilaterally). Abnormal heart sound (S3)
● Dental exam: 1 year ago with no complications.
● Gynecologist Prostate exam: 2 years ago with no abnormal findings.
4. Health Habits
● Eats fruits and vegetables. Rarely eats fried food. Drink a sufficient amount of fluids such as water, orange juice and protein milk. Walks once a week and exercise every morning.
5. Health concerns
● Patient stated, “I am tired all the time and I have no energy.”
● Patient stated, “I tried to cut down on smoking but failed at it. I have a cough and feel short of breath most of the time.”
6. Addressing concerns
● Worried about another heart failure. Addresses his concern about shortness of breath due to smoking.
7. What would the patient like to improve about his overall health?
● Stop smoking to avoid risk of lung failure.
● Start eating more fresh vegetables and fruits, low sodium diet and avoiding fried food. Stay hydrated.
● Patient stated, “I want to exercise and walk at least twice a week.”
B. Document the Health History
P.S. is a 56-year-old male whose height is 5’ 10’’ and weighs 150 lbs. He was admitted to the hospital due to irregular heart rate and rhythm and changes in Electrocardiogram (ECG) indicating irritability of the heart failure. He also had a high blood pressure. He has a history of Myocardial Infarction (MI) at age 51. Besides this, Mr. P.S. reports, “I am tired all the time. I have no energy.” He has bilateral +2 pedal edema, decreased peripheral pulse (radial pulse +1 bilaterally; pedal pulse +1 bilaterally), orthopnea (needs to sleep in an upright position with 3 pillows), and audible S3 heart sound (extra heart sound which indicates heart failure). He urinates 5-6x a day and has bowel movements every other day (1-2x a day). Mr. P.S. reports, “I tried to cut down on smoking but failed at it. I have a cough and feel shortness of breath most of the time. I have problems with catching my breath.” Respiratory rate is 27/min; pulse oximetry is 91%; no cyanosis noted. He has a healthy diet with fruits and juices as of now. His normal diet consists of protein, whole grains, low-fat dairy products and low sodium diet, but eats fried, and unhealthy food twice a month. The patient doesn’t participate in any recreational drugs but smokes one pack in two weeks. Last physical examination was a week ago with some complications such as edema, decreased pulse and abnormal heart sound (S3). Patient was engaged in weekly exercise and walking to maintain his health. He is currently admitted for treatment of cardiac irregularities and heart failure.
C. List of potential Nursing Diagnosis
● Decreased Cardiac Output
➢ Subjective Data
Patient stated, “I am all tired. I have no energy.”
Patient stated, “I have a cough and feel shortness of breath most of the time.”
Patient stated, “I have problems catching my breath.”
➢ Objective Date
Patient has irregular heart rate and rhythm and changes in the ECG.
Decreased peripheral pulse radial +1 bilaterally, pedal +1 bilaterally.
Pulse oximetry was 91%. Patient has hypoxia (lack of oxygen)
Patient has an extra heart sound S3 which indicates heart failure.
● Ineffective Breathing Pattern
➢ Subjective Data
Patient stated, “I am tired all the time and have no energy.”
Patient stated, “I have problems catching my breath.”
Patient stated, “I have a cough and feel shortness of breath most of the time.”
➢ Objective Data
On examination patient’s respiratory rate was 27/min.
Upon auscultation patient has crackles on the lung bases bilaterally.
● Risk for Pulmonary Related Diseases
➢ Subjective Data
Patient stated, “I have problems catching my breath.”
Patient stated, “I tried to cut down on smoking but failed at it. I have a cough and feel shortness of breath most of the time. I have problems with catching my breath.”
➢ Objective Data
Smoking once a week shows the increased risk of pulmonary diseases and lung cancer.
● Activity Intolerance
➢ Subjective Data
Patient stated, “I am tired all the time and have no energy.”
➢ Objective Data
Patient has decreased peripheral pulse, radial +1 bilaterally and pedal +1 bilaterally.
Bilateral +2 Edema. Respiratory rate is 27/min with pulse oximetry 91%.
Priority Nursing Diagnosis
Decreased Cardiac Output r/t hypoxia aeb (as evidenced by) irregular heart rate and rhythm. Based on the patient’s condition Decreased Cardiac Output is the priority nursing diagnosis as the patient has cardiac irregularities, low pulse oximetry 91% and high respiratory rate 27/min. This is evidenced by patient stated, “I feel shortness of breath and tired all the time.”
The Interview Experience
The experience of conducting a health history on a patient was challenging as well as an enormous learning experience. I went to a rehabilitation center for conducting an interview. This was my first time conducting a health history interview so I was nervous. First I thought it was just an interview and would be really easy. But as I started asking questions it was challenging and required great patience and communication skills. Developing trust is very important to get appropriate health information from the patient. My verbal communication skills helped me in seeking proper health information from the patient. As I asked questions about the patient’s condition I could correlate all the diagnosis effective for my concept map.
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The most challenging part was collecting information which was measurable and precise. After collecting the information I had to think critically how to plan, implement and evaluate the nursing diagnosis. This was my first time interviewing so, I wasn’t able to ask more specific questions about the signs and symptoms of the disease which made difficult for me to critically think and relate all the diagnosis and decide on a care plan. What I would do differently next time is, I would ask more precise information about their lifestyle and eating habits. I would also ask their chief concern about the disease and more specific information about seeking health care. This would help me create an evaluation which is measurable, realistic and time framed.
This assignment was a fabulous and an amazing experience for me to look at the nursing process in a broad way.
Conclusion
Overall, I never thought that obtaining patient’s health history was very important for making a diagnosis. I used to fill the health history form just for the sake of filling, but now I know how important it is for the doctors and nurses to make an appropriate course of treatment for the patient. It is important that we know the patient's concerns and risk factors for a particular disease. To know that, we should have accurate data of the patient's current health status, past medical history and patient’s complaints. Another factor which I learned is communication. If you want to obtain appropriate information from the patient, it is important to build a trust between you and the patient so that he/she is able to share any health concerns with you. Fundamentals of the health history are very important to decide on a care plan. From this assignment I learned that it is important to obtain health history from a patient and how each an every risk factor is important for diagnosis. This was an enlightening experience for me and I really felt like a nurse for a moment. Thank you for implementing this assignment as a course of study for the Nursing program.
References
- Ackley, B. J., & Ladwig, G. B. (2015). Nursing diagnosis handbook: an evidence-based guide to planning care. Tenth edition. Maryland Heights, Missouri: Mosby Elsevier.
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