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2 pages/≈550 words
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Subject:
Health, Medicine, Nursing
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English (U.S.)
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Topic:

Nursing Concept Mapping (Coursework Sample)

Instructions:

A NURSE'S APPROACH TO A PRESENTED CASE.

source..
Content:


Concept mapping
Name
Institution
STEP 1: DEVELOP A BASIC SKELTON
4429125222250Profound fatigue00Profound fatigue2124075203200 Lactose deficiency00 Lactose deficiencyleft203200Anorexia00Anorexia
436245012172955-10 stools a day005-10 stools a day476251083945 Frequent nausea00 Frequent nausea
43815001416050 Underweight (39kg)00 Underweight (39kg)209550044450REASON FOR SEEKING HEALTH CARE:Recurrent00REASON FOR SEEKING HEALTH CARE:Recurrent
left54610 Very thin00 Very thin
28575302260 Diarrhoea00 Diarrhoea4419600359410 Recurrent abdominal pain00 Recurrent abdominal pain
204787530480Dehydration00Dehydration
2162175359410PainAbdominalIntractable abdominal painIncapacitating pain 00PainAbdominalIntractable abdominal painIncapacitating pain left378460Fluid imbalanceDehydration00Fluid imbalanceDehydration4391025378460Body weightAnorexiaUnderweightthinness00Body weightAnorexiaUnderweightthinnessSTEP 2: ANAYZE & CATEGORIZE THE DATA
9525320675InfectionSeverely inflamed bowel00InfectionSeverely inflamed bowel2190750301625Post op 2 days. Severely inflamed and friable bowelTemporary ileostomy EstablishedPriority assessment: open wound, perforation on her small bowel00Post op 2 days. Severely inflamed and friable bowelTemporary ileostomy EstablishedPriority assessment: open wound, perforation on her small bowelright320675Stomach discomfortUnrelenting nauseaVomiting61 cm of colon removed00Stomach discomfortUnrelenting nauseaVomiting61 cm of colon removed
2200275133985MobilitySo weak, cannot stand00MobilitySo weak, cannot stand
43910254165607. Body weightAnorexiaUnderweightthinness007. Body weightAnorexiaUnderweightthinnessSTEP 3: ANALYZE NURSING DIAGNOSES RELATIONSHIPS
21621753594102. PainAbdominalIntractable abdominal painIncapacitating pain 002. PainAbdominalIntractable abdominal painIncapacitating pain
2428875502920004933950188595401002584582019907258172453724275521970right8261353. Stomach discomfortUnrelenting nauseaVomiting61 cm of colon removed003. Stomach discomfortUnrelenting nauseaVomiting61 cm of colon removed2190750864870Post op 2 days. Severely inflamed and friable bowelTemporary ileostomy EstablishedPriority assessment: open wound, perforation on her small bowel00Post op 2 days. Severely inflamed and friable bowelTemporary ileostomy EstablishedPriority assessment: open wound, perforation on her small bowel9525320675InfectionSeverely inflamed bowel00InfectionSeverely inflamed bowel
1143004749806. Infections, post-surgical fluids/ drainsSalem sump nasogastric tube (NGT)Jackson pratt (JP) drain to bulb sunction0200006. Infections, post-surgical fluids/ drainsSalem sump nasogastric tube (NGT)Jackson pratt (JP) drain to bulb sunction
42862507937500019812004318003049906105092500220027511747505. MobilitySo weak, cannot standPost-surgical 005. MobilitySo weak, cannot standPost-surgical 44767506794504. Vital signs112/72, 86, 24,100.8°F004. Vital signs112/72, 86, 24,100.8°F
STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS
* The patient is responding to treatment most importantly from the outcome of the top three priority nursing diagnosis we carried out. Her surgery wounds are healing after surgery was performed to repair bowel perforation together. Before healing, she is still going to be fed via tubes. Her temperatures are normalizing by the day and she will recover from the traumatic depression she has undergone, especially if her only family give her support and company.
* After we notice some improvements, she will be assessed by the nutritionist and we shall put her on diet for her to gain weight.
* We are still going to monitor her so that her healing wounds do not get bacterial infections. We are trying to ensure this does not recur as 4 da

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