Nursing Concept Map 2.docx - Concept Map (TEMPLATE) Student...

This preview shows page 1 - 2 out of 5 pages.

The preview shows page 1 - 2 out of 5 pages.
(VM/GP/KL-V5)Concept Map(TEMPLATE)Student Name:Instructor:DATE Care Provided and UNIT:10/9/2021Patient Information(1)Patient Initials: R.M.Age & Gender: 32/MaleHeight/Weight: 184 cm/ 93.6 kgCode Status: Full codeLiving Will/ DPOA: NoneHistory of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1).WHAT BROUGHT THE PT TO THE HOSPITAL?WHAT EVENTS LEAD UP TO THIS?WHAT HAPPENED WHEN THEY GOTTO THE HOSPITAL- UNTIL NOW WHEN YOU ARE PROVIDING CARE?(USE SEPARATE ATTACHED WORD DOCWHEN NEEDED)R.M. came into the ER stating in his own words: “I haven’t been feeling good. I feel so nauseous. My stomach has been hurtingme since yesterday, like it’s stabbing me, and I don’t want to even look at any food.” Today, I threw up seven times and I feelreally weak.”Vital signs were taken and found at BP 107/63 HR 106 RR 21 Temp 100.9 SPO2 100% on room air. Patient reports abdominalpain 9/10 in the umbilicus and epigastric regions. Patient states lying down makes the pain better but not much and sitting upor movement makes the pain worse. Per patient the pain is sharp/stabbing and is intermittent after vomiting. Patient has anelevated temperature which may indicate infection. Patient is tachycardic and patient stated his “blood pressure is lower thanit normally is”. Mental status is Alert and oriented x4. Patient’s blood was drawn and sent to lab for CBC and BMP. IV wasinserted in the right forearm. Patient was given ondansetron SL and patient was started on 1000mL of NS. Patient’s I&O and VSwill be closely monitored every 2 hours.Medical History: (SEE RUBRIC REQUIREMENTS)PAST DIAGNOSED MEDICAL PROBLEMSChildhood AsthmaSurgical History: (SEE RUBRIC REQUIREMENTS)No previous surgical historySocial History:SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USEALCOHOL/ ELICIT DRUG USEPatient denies smoking or illicit drug use. Patient reports moderate alcohol consumption.Chief ComplaintNausea & vomiting x 2 days. Sharpstabbing pain in stomach. Feels weak.Admitting Diagnosis & Admission DateDehydration related to possiblegastroenteritis 10/9/2021Erickson’s Developmental Stage Related to pt. & Cite References (1)*List and Discuss specificstage(based on objective assessment)R.M. belongs to the 6thstage of Erickson’s Developmental Stages:Intimacy vs. IsolationIn the sixth stage of Erikson’s psychosocial development theory,young adulthood takes place between the ages of 18 and 40. Duringthis time, major conflict can arise as we attempt to form longer termcommitments outside of our family, with varying degrees of success(Sutton, 2020).

Upload your study docs or become a

Course Hero member to access this document

Upload your study docs or become a

Course Hero member to access this document

End of preview. Want to read all 5 pages?

Upload your study docs or become a

Course Hero member to access this document

Term
Winter
Professor
Katrina Lino
Tags
Hypovolemia, Intravenous therapy

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture