NUR 3219C Keiser University Care Management Concept Map

NUR 3219C Care Management II- Concept Map – Summer 2022Name: ___________ Date: ________
Client Initials: RC
Room: 211
Age: 69
Plan of care:
Sex:Continue/revise/d
F
______________________________________________________________________________
Chief Complaint
Weight: 120 Lb.
Admitting Dx: Respiratory Distress, Covid+
Height: 5.3
Admitting Diagnosis: Respiratory
Medical Hx: Respiratory Failure/Pneumonia
Distress, Covid+
Physical Assessment Data:
Chronic Diseases: Respiratory
Failure/Pneumonia
Pathophysiology of Medical
(Client-specific)
#
Prioritize
#
Prioritize
Prioritize
#
Key Problem/ND:
Subjective / Objective Data:
Key Problem/ND:
Subjective / Objective Data:
Key Problem/ND:
Subjective / Objective Data:
Maslow’s:
Maslow’s:
Maslow’s:
Diagnosis:
Potential Complications:
Nursing Diagnosis (1): ___________________________________
EXPECTED OUTCOMES (must be measurable;
follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included)
Nursing Intervention Classification (NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported by client’s
response; include plan of care – e.g. revise,
continue, discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Short-term Goal 2:
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Long Term Goal:
Nursing interventions for LT Goal :
Evaluation for LT Goal :
Nursing Diagnosis (2): ___________________________________
EXPECTED OUTCOMES (must be measurable;
follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included – cited & referenced)
Nursing Intervention Classification (NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported with evidence;
include a plan of care – e.g. revise, continue,
discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Short-term Goal 2:
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Long Term Goal:
Nursing interventions for LT Goal :
Evaluation for LT Goal :
Nursing Diagnosis (3): ___________________________________
EXPECTED OUTCOMES (must be measurable;
follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included – cited & referenced)
Nursing Intervention Classification (NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported with evidences;
include plan of care – e.g. revise, continue,
discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Short-term Goal 2:
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Long Term Goal:
Nursing interventions for LT Goal :
Evaluation for LT Goal :
References: (APA 7th Ed)
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Zanotti, M., & Martinez-Kratz, M. R. (2022). Nursing diagnosis handbook: An evidence-based
Guidr to Planning Care. Elsevier.
NUR 3219C Care Management II- Concept Map – Summer 2022
Name: _____Rachel Melo__________ Date: _6/20/22______
Client Initials: A.G
Chief Complaint: pain
Room:211
Admitting Dx: chronic pain
Age:Plan
75 of care: Continue/revise/d
Medical Hx: metastatic gastric cancer
Sex:______________________________________________________________________________
M
Physical Assessment Data: pain 7/10, SOB, AAOx2
Weight: 120 lbs
Neuro: AAOx2 (person & place), motor deficit, muscle strength 1/5 bilaterally, sensation intact bilaterally.
Height: 5’10”
Respiratory: percussion: tympanic in all zones, auscultation: patent airway, normal breath sounds.
Admitting Diagnosis:
Observation: SOB
Pain
Cardiovascular: PMI not visible, but able to auscultate in the 5th intercostal space in the midclavicular line
Chronic Diseases: metastatic
on the left side, chest normal in appearance, no murmurs, gallops or rubs auscultated.
GI: bowel sounds hypoactive, less than 5 per minutes were auscultated, reported unintentional weight loss.
gastric cancer.
GU: hematuria, feces were watery green.
Extremities: no edema, skin intact, no vocable abnormalities,
Pathophysiology of Medical
Skin: skin turgor showed no sign of dehydration., skin integrity intact.
(Client-specific)
Musculoskeletal: pain in both knees, the knees felt hot to the touch.
Chronic pain is characterized by
Vitals: BP: 130/72, RR: 18, HR: 97, SPO2: 92 NC 3O2, Temp (F): 98.3.
abnormal sensitivity, which is
due to the generation of pain in
response to the activation of the
Key problem: Weight loss
Key problem: oncoming
low threshold mechanoreceptive
Key problem: Pain
ND:
Imbalanced
nutrition:
death, fear of death.
A beta fibers that normally
ND: Chronic pain r/t malnutrition
less than body requirements
ND: Powerlessness r/t effects
generate innocuous sensations.
AEB dysphagia.
r/t inability to ingest food
of illness, oncoming death
Subjective: Pt reported pain
Diagnosis:
because of biological factor
AEB patient crying and
@7/10 in the 1-10 scale. I was
AEB weight loss.
Chronic pain
saying he does not want to
able to observe grimaces in the pt
Objective: Pt dropped from
face.
die.
Complications:
175 lbs to 120 lbs in 3
Objective: Difficulty swallowing
Subjective: Pt cries and asks
months. You can observe that
(dysphagia). I observed the pt
for help, he states that he feels
Decreased quality of life,
the patient barely has muscle
eating, and he is in a puree diet
sad because he cannot do the
depression, anxiety, substance
because it is extremely difficult
or fatty tissue. Subjective: pt
things he used to do, he feels
abuse disorder, worsening of
for the pt to swallow. Which
states that he feels weak, and
useless.
existing chronic disease, an
leads to low food intake, which
that he has noticed that there
Objective: patient is unable to
increase risk suicidal ideation
lead to malnutrition.
is no more muscle or fat left
Maslow’s:
move, unable to eat and
and/or suicide.
in his body, that all he can see
Physiological
unable to perform activities on
are his bones.
Orders:
his own.
Maslow’s
Percocet PO 1500, 2100
Maslow’s:
Physiological
Morphine IV 1800, 2300, 0200
Safety Needs
Order
Benadryl 25 mg IV q 8hrs PRN
Order
Pureed Diet
Lorazepam IV 2300, 0200
Music therapy
Diphenhydramine IV 0930
Nursing Diagnosis (1): Chronic pain r/t malnutrition AEB dysphagia.
EXPECTED OUTCOMES (must be
measurable; follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included)
Nursing Intervention Classification
(NIC):
__________________________________
EVALUATION (state if met, partially met,
or not me; must be supported by client’s
response; include plan of care – e.g. revise,
continue, discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Perform a pain assessment using a reliable
self-report pain tool. EB: Tools such as
the 0 to 10 NRS or faces pain scale (FPS)
assess pain intensity. Multidimensional
tools such as the Brief Pain Inventory
(BPI), McGill Pain Questionnaire (MPQ),
the Pin Relief Scale (PRS), or the Chronic
Pain Grade Scale (CPGS) provide a
comprehensive evaluation of the client
with persistent pain assessing the
characteristics and quality of pain;
satisfaction with pain control; and how
pain affects mood, activity, sleep, and diet
(Fillingim et al, 2016; Drew & Peltier,
2018, as cited in Ackley et al, 2022).
Ask the client to describe prior
experiences with pain, effectiveness of
pain management interventions, responses
to analgesics medication including
occurrences of side effects, and concerns
about pain and its treatment (e.g., fear
about addiction, worries, anxiety) and
Goal was met. The patient was able to rate his
pain in the 1 to 10 scale, initial assessment of
pain was 7/10. The pt explained how pain
affected his sleep, mobility and eating patterns.
He was able to describe his previous
experience with pharmacologic agents and
how they aid with pain reduction. A
continuous assessment of pain will be
followed with the PQRST method in mind.
Continue with the plan of care.
Pain level will be assessed with the 1-10
scale, this assessment will be done by asking
the pt to place the pain they are feeling in a 110 scale, this assessment will take
approximately 10-15 minutes.
informational needs. EBN: Obtaining an
individualized pain hx helps identify
potential factors that may influence the
client’s willingness to report pain, as well
as factors that may influence pain
intensity, the client’s response to pain,
anxiety, and pharmacokinetics of
analgesics (Drew & Peltier, 2018, as cited
in Ackley et al, 2022).
Assess chronic pain regularly including
the impact of chronic pain on activity;
sleep, eating habits, and social conditions
including relationships, finances, and
employment. CEB: Regular assessment of
clients with chronic pain is critical
because changes in the underlying pain
condition, presence of comorbidities, and
changes in psychosocial circumstances
can affect pain intensity and
characteristics and require revision of the
pain management plan (Turk et al, 2016,
as cited in Ackley et al, 2022). EB: Sleep
disturbances and decreased physical
activity are adverse effects of people with
chronic pain (Ackley et al, 2022).
Short-term Goal 2:
.
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
If opioid therapy is considered, assisted
the provider with aspects of an opioid risk
Goal met; the initial evaluation yielded a pain
level of 7/10 confirmed by the client. After the
Goal is to reduce pain from 7/10 to 3/10
within 2 hours by using pharmacological and
non-pharmacological approaches.
assessment, which includes a
comprehensive client interview and
examination with pain focus, mental
health screening, use of an opioid risk
assessment tool, examination of
prescription drug monitoring program
results and urine drug screening. EB:
Although prevalence rates vary, there is
evidence of opioid misuse and substance
use disorder (SUD) among those who are
prescribed opioids, this to reduce risk and
optimize safe opioid use, risk assessment
and stratification are recommended (APS,
2016; Dowell, Haegerish, & Chou, 2016;
Hudspeth, 2016, as cited in Ackley et al,
2022).
In addition to administering analgesics,
support the clients use of
nonpharmacological methods to help
control pain, such as distraction, imagery,
relaxation, and application of heat and
cold. EBN: Evidence suggested efficacy
and satisfaction when complementary
therapies are integrated into pain
treatment plan of older adults
(Bruckenthal, Marino, & Snelling, 2016,
as cited in Ackley et al, 2022).
Explain to the client that pain
management approach that has been
ordered or revised, including therapies,
medication administration, side effects,
administration of analgesics (Percocet PO
1500, 2100, Morphine IV 1800, 2300, 0200,
Benadryl 25 mg IV q 8hrs PRN, Lorazepam
IV 2300, 0200, Diphenhydramine IV 0930),
and non-analgesic (repositioning and rubbing)
therapy, the patient stated his pain to be 3/10
on the 1 to 10 scale. Plan of care will be
continued, and the interventions performed
were successful in achieving the goals.
Long Term Goal:
Improved mental wellbeing will be achieve
within a week of the client arrival at hospice
care.
and complications. EB: One of the most
important steps toward improved control
of pain is a better client understanding of
the nature of pain, its treatment, pain
management, goals, and the role the
clients need to play in pain control
(Curtiss & Wrona, 2018, as cited in
Ackley et al, 2022).
Nursing interventions for LT Goal:
Cognitive behavioral (mind-body)
strategies can restore the client’s sense of
self control, personal efficacy, and active
participation in his or her own care
(Broderick et al, 2014, as cited in Ackley
et al, 2022). EB: Motivational
interviewing a counseling method that
aims to resolve a client’s ambivalence
about behavior change, may improve
chronic pain treatment adherence, but
more study is needed to determine
whether it will improve pain intensity and
function (Alperstein & Sharpe, 2016, as
cited in Ackley et al, 2022).
Discuss the client’s fears of undertreated
pain, side effects, opioid use disorder
(OUD), and overdose and reassure the
client that there will be a regular
assessment and treatment of pain and
assessment for side effects and signs of
OUD. EBN: Cogan et al (2014), as cited
Evaluation for LT Goal:
Goal partially met, after an interview with the
patient it was discovered that even though he
is more accepting of the side effect of the
analgesic therapy and the pain he is suffering,
he is still worried about the imminent threat of
death. Plan of care will be to continue to
include the patient in the decision making of
his care as well as to continue discussing his
fears related to his disease and death. Plan of
care should also be revised to include other
interventions that will aid the patient to
achieve this goal.
in Ackley et al (2022) reported that among
379 clients scheduled for cardiac surgery,
31% stated that it is easy to become
addicted to pain medication, 20% report
that “good patient” do not talk about their
pain, and 35% believed that pain
medication should be “saved in case the
pain worsens”.
If the client has progressive cancer pain,
assist the client and family with handling
issues related to death and dying and
provide access to palliative care programs
and hospice services. CEB: In a study by
Tennel et al (2010), as cited in Ackley et
al (2022), clients with non-small cell lung
cancer who receive early palliative care
interventions had significant
improvements in quality of life and mood,
less aggressive care at the end of life, and
longer survival.
Nursing Diagnosis (2): Imbalanced nutrition: less than body requirements r/t inability to ingest food because of biological factor AEB weight loss.
EXPECTED OUTCOMES (must be
measurable; follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included – cited & referenced)
Nursing Intervention Classification
(NIC):
__________________________________
EVALUATION (state if met, partially met,
or not me; must be supported with evidences;
include plan of care – e.g. revise, continue,
discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Monitors state of oral cavity (gums,
tongue, mucosa, and teeth). Provide good
oral hygiene before each meal. Good oral
hygiene enhances appetite; the condition
of the oral mucosa is critical to the ability
to eat. The oral mucosa must be moist,
with adequate saliva production to
facilitate and aid in the digestion of food
(Ackley et al, 2022).
Recognize the characteristics that classify
individual as malnourished and refer to a
dietician for a complex nutritional
assessment and intervention. CEB:
According to the Academy of Nutrition
and Dietetics and the American Society of
Parenteral and Enteral Nutrition, two or
more of the following characteristics are
recommended to support the diagnosis of
malnutrition: insufficient energy intake,
weight loss, loss of muscle mass, loss of
subcutaneous fat, localized or generalized
fluid accumulation, and/or decreased
Goal met; patient was able to recognize that
dysphagia is one of the main factors
contributing to him being underweight. He
stated that he was in fact in pain when
swallowing and it was very hard and tiresome
for him to finish a meal. Furthermore, he
understood that based on the exponential
weight loss he experiences, he met the
parameters to be included in the underweight
group. Plan of care is to continue educating the
client of the different ways he can help himself
or ask the nurse to do before eating so that the
action is more bearable. Plan of care will
continue as the plan of care provided helped
the patient meet the goals provided.
Patient will be able to recognize that factors
contributing to him being underweight by the
end of the day.
Short-term Goal 2:
Patient will be able to identify the nutritional
requirements that he needs by the end of the
day.
functional status (White, Guenter, &
Gordon, 2012, as cited in Ackley et al,
2022).
Screen for dysphagia in older clients. EB:
A study found that prevalence of
dysphagia was higher than malnutrition in
older patients. Dysphagia was also an
independent risk factor for malnutrition an
both conditions were related to poor
outcomes (Carron et al, 2015 as cites in
Ackley et al, 2022).
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Note laboratory values cautiously;
decrease in albumin and prealbumin may
be indicators of the inflammatory
response that often-accompanied acute
malnutrition, but it should not be used to
diagnosed malnutrition. Other potential
factors of inflammatory response include
C-reactive protein, white blood cell count,
and blood glucose values (Ackley et al,
2022).
Considering offering healthy snacks such
a yogurt, which is a good source of
proteins, calcium zinc, B vitamins and
probiotics. EB: Observational studies
suggest that yogurt could play an
important role in improving the nutritional
health of older adults when combined with
Goal partially met; the client was able to
understand that he needed to consume protein
to meet the nutritional requirements that he
needed to move from the group of
malnourished to nourished. However, patient
failed to understand the importance that labs
must help determine what the patient is
lacking in his current diet. Plan should be
revise, and new plan of care should include
more education about the different ways there
are to determine the nutritional requirements
that the patient needs.
Long Term Goal:
Patient will progressively gain weight within
3 months to reach the desired goal, 170 lbs.
a healthy diet (El-Abbadi et al, 2014, as
cited in Ackley et al, 2022).
Advocate for the implementation of a
feeding protocol, if not already in place, to
avoid unnecessary and or prolonged
nothing by mouth/clear liquid diet
(NPO/CLD) status in hospitalized
patients. EB: A study found that on
average patients with unjustified NPO or
CLD order spent 3 days on an NPO or
CLD diet, which corresponded to a mean
of 10 missed meals (Gallinger et al, 2017,
as cited in Ackley et al, 2022).
Nursing interventions for LT Goal:
Evaluation for LT Goal:
Weight the client daily in acute care and
weekly to monthly in extended care at the
same time (usually before breakfast) with
the same amount of clothing (Ackley et al,
2022).
Administer antiemetics and pain
medications as ordered and needed before
meals. The presence of nausea or pain
decrease appetite (Ackley et al, 2022).
Recognize the importance of offering
high-protein food and beverages to most
hospitalized individuals (use caution wit
those with compromised renal/liver
function). EB: A study found that
maintaining adequate dietary protein aids
in muscle mass preservation during period
Goal partially met, the patient was able to gain
7 lbs, however, the patient did not meet the
desired weight of 170 lbs. The diet of the
patient was changed from regular to pureed so
that the patient will be able to eat better and
will spend less energy while doing so. A
pureed diet will also reduce the pain during the
swallowing process. Plan of care should be
revised, and the long term goal should be
extended to accurately reflect the amount of
time it would take the patient to reach ideal
weight of 170 lbs.
of muscle disused. Such strategies are
particular relevant to the older patients
who is a risk of developing sarcopenia
(Wall & van L00n, 2013, as cites in
Ackley et al, 2022).
Nursing Diagnosis (3): Powerlessness r/t effects of illness, oncoming death AEB patient crying and saying he does not want to die.
EXPECTED OUTCOMES (must be
measurable; follow SMART)
Nursing Outcome Classification (NOC):
_____________________________________
INTERVENTIONS (rationale must be
included – cited & referenced)
Nursing Intervention Classification
(NIC):
__________________________________
EVALUATION (state if met, partially met, or
not me; must be supported with evidences;
include plan of care – e.g. revise, continue,
discontinue POC)
Short-term Goal 1:
Nursing interventions for ST Goal 1:
Evaluation for ST Goal 1:
Assess powerlessness with tools that are
available for general and specific clients’
groups:
 Measure of Powerlessness for Adults
Patients (De Almeida & Braga, 2006,
as cited in Ackley et al, 2022).
 Personal Progress Scale-Revised,
tested with women (Johnson, Worell,
& Chandler, 2005, as cited in Ackley
et al, 2022).
 Life Situation QuestionnairePowerlessness subscale, tested with
stroke caregiver (Larson et al, 2005, as
cited in Ackley et al, 2022).
 Making Decisions Scale, tested in
clients with mental illness (Hansson 7
Bjorkman, 2005, as cited in Ackley et
al, 2022).
 Family Empowerment Scale, tested on
parents of children with emotional
disorders (Kore, DeChillo, & Friesen,
1992, as cited in Ackley et al, 2022).
Goal met, the client was able to clearly state
his feeling of powerlessness and the reasons
why he was feeling this way. The specific
method used was the Measure of
Powerlessness for Adults. Patient was able to
understand that factors like his immobility,
hospitalization and chronic illness were all
aspects adding to his feeling of powerlessnes.
Plan of care should be continued as it helped
achieve the goal stated for this patient.
Client will be able to states his feelings of
powerless and feelings related to
powerlessness by the end of they day
Short-term Goal 2:
Client will ask questions about care and
treatment, and he will be more
knowledgeable about it by the end of the day.
Observe for factors contributing to
powerlessness (e.g., immobility,
hospitalization, unfavorable prognosis,
lack of support system, misinformation
about situation, inflexible routine, chronic
illness, addiction, hx of trauma, gender).
Help clients channel their behaviors in an
effective manner. EB: Many studies
identify factors contributing to feelings of
powerlessness are related to losses of
person, place, health, or social
relationship; gender, or the effect of
trauma (Salome et al, 2013; Doyle, 2014,
as cited in Ackley et al, 2022).
Use rehabilitative behavioral learning
model that assist clients to understand
how the mechanisms of habit and ritual
work to reinforce powerlessness in their
lives. For clients with addiction,
understanding the learning process and
mechanism of powerless is an important
part of recovery (Butler et al, 2015, as
cited in Ackley et al, 2022).
Nursing interventions for ST Goal 2:
Evaluation for ST Goal 2:
Engage with client using respectful
listening and questioning to develop and
awareness of client’s most important
concerns. EB: Engaging clients will
integrate clinician expertise with client
needs and can diminish feelings of
Goal partially met, even though the client was
referred to an empowerment group, he was not
completely sharing his thoughts about his own
powerlessness. However, all the nurses
associated with the client care would
empathize and lend a friendly ear to which the
Long Term Goal:
Client will be able to verbalize hope for the
future and sense of participation in planning
and implementing care by the end of the
month.
powerlessness (Sheridan et al, 2015, as
cited in Ackley et al, 2022).
Provide health education for older
individuals that is tailored, interactive,
structured, continuous, and incorporates
motivational and encouragement
techniques. EB: A systematic review of
the literature showed that use of specific
educational interventions for older nursing
home residents was empowering strategies
that increased self-efficacy and self-care
(Shoberer et al, 2016, as cited in Ackley et
al, 2022).
Assess for the influence of
communication patterns, cultural
differences in medical consultations, and
client perceptions of inequalities in care
quality as contributors to client feelings of
powerlessness. EB: Understanding and
addressing client perceptions of power
disparities may decrease clients’ feelings
of powerlessness (Akhavan & Karlsen,
2013, as cited in Ackley, 2022).
Nursing interventions for LT Goal:
client took advantage of and talked about his
feelings of powerless in the privacy of his
room. Furthermore, client was able to
understand the education provided about
different motivational and encouragement
techniques, trough the repeat back method
Plan of care should be revised and updated
with new interventions that will aid the patient
achieve this specific goal.
Refer client to an empowerment support
group. EBN: A randomized controlled
trial found that clients who participated in
an empowerment support group showed
significant increases in levels of
empowerment and self-care behaviors
Goal partially met; patient is still fearful of
what kind of future awaits him. Even though
support and educational interventions were
provided, and his understanding was checked
through the repeat back method, his feelings or
powerlessness have not completely gone away.
Evaluation for LT Goal:
(Hsiao et al, 2016, as cited in Ackley et al,
2022).
Provide support and educational
interventions that are culturally tailored.
EB: A randomized control trial found that
Latino families assigned to a culturally
sensitive, cognitive-behavioral (CBT)
group intervention reported lower
neuropsychiatric symptoms in their
relative, less caregivers distress, a greater
sense of caregiver self-efficacy, and less
depressive symptoms over time (Gonyea,
Lopez, & Velasquez, 2016, as cited in
Ackley et al, 2022).
Provide support for client’s family to
identify the balance between client care
responsibilities and self-care. EBN: A
recent study found that by supporting
client families and considering them as
resources, family feelings of
powerlessness can be reduced (Lindgren,
Soderberg, & Skar, 2016, as cited in
Ackley et al, 2022).
Support to the client’s family was provided as
well, so they can further help the client
through his journey. Plan of care should be
revised and new interventions that will help
achieve this goal should be added.
References: (APA 7th Ed):
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Zanotti, M., & Martinez-Kratz, M. R. (2022). Nursing diagnosis handbook: An
evidence-based Guidr to Planning Care. Elsevier.