STUDENT NAME:Minnie Mouse
Patient Initials:PB
COMFORT-
Pain 6/10
Vicodan 1 po q 4 hours prn
Kefzol 1 gm IV q 8 hours
Wound on right thigh
Turn/reposition q 2 hours
NGT low suction
1
Completed Sample CONCEPT MAP -8 Basic Needs
Assessment and Nursing Diagnosis
OXYGENATION
Reason for seeking healthcare:
Trauma; fractured right hip w/ORIF;
1800 ADA after NGT removed
IV- RL @ 40 ml/hr
FBS – 227
Humulin N
weakness
Imbalanced Nutrition: less than body req
138/92. P= 110; O2 sat= 94% 3L n/c
Pale; dyspneic; confused;
Hgb 10.4
Incentive Spirometry.
Ineffective tissue perfusion
I don’t know how this fits with the
concepts.
Widower?
Acetaminophen?
Smokes?
2
SAFETY
NURSING DIAGNOSIS (# in Priority) ELIMINATION
TEACHING PSYCH/SOCIAL
PMH: pacemaker; depression;
PRIORITY ASSESSMENTS:
1) Pain
2) LOC
3) Lung sounds
4) Wound care
Risk for falls; lives alone; confused;
wheelchair;
Impaired physical mobility
Glasses; hard of hearing;
Poor English; speech mumbled;
anxiety
Nursing Diagnosis
Medications
Wound care
Insulin injections
Knowledge deficit
Anxiety; lives alone; no family;
Jewish
Nursing Diagnosis
Foley-urine dark amber
Lasix 20 mg po daily
Output= 800/24 hrs.
Stool –black/semi-soft
Nursing Diagnosis
3
8
6
/
-
Alt in Comfort
diabetes; Hypertension; COMMUNICATION
NUTRITION
