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Acute Care Patient Paper and PPT

Acute Care Patient Paper and PPT

Acute Care Patient Paper and PPT

Acute Care Patient Paper and PPT

78 YO African-American Female Religion: Baptist Full Code


Presented via ambulance from a nursing home where he is a long term resident. He had altered mental status. 2 days ago he had a fall


He has past medical history of Dementia, Diabetes Type 2, Depression, HTN, CAD,


Home Meds: Enelapril, Lopressor, Cardizem, glipizide, Senna, Lovastatin. Gabapentin, Calcitrate

with D, tylenol. Acute Care Patient Paper and PPT


Physical Exam:

Neuro: Alert, confused, clear speech. Able to follow command

CVS: heart s1 s2 no murmur, HR 110 regular BP 120/69 cap refill > 2 seconds, no peripheral

Edema. Saline lock line left forearm

Resp: lungs diminished throughout. Cough productive, unlabored resp, RR 24. Pulse oximeter

93% on oxygen 2l/min by nasal cannula

GI: Bowel sounds-normoactive , Abd soft, non-tender. Poor oral intake, bowel incontinent

GU: urinary incontinence

Muscskel: non-ambulatory, requires one assist to chair

Skin: No bruises, rashes. No skin breakdown


Admitting diagnosis: Pneumonia, Acute Kidney Injury, encephalopathy, symptomatic,


Hospital Medications: Heparin 5000 U Q12h SQ, Zosyn , Kay Exalate,


Diagnostic Test:

Chest Xray: bilateral pneumonia

Head CT- no acute changes, atrophy consistent with aging, NURS 410 Bowie State University Acute Care Patient Paper and PPT

Chest CT- Hilar mass with lymphadenopathy

EKG- no changes

BMP: Glucose 180, Na 141, Cl 110, K 6.2, BUN 30, Creat 2.7, Ca 16.9

CBC: WBC 26.1 Hgb 11.2, Hct 33.3, Plt 150, HCO3 23


Bowie State University School of Professional Studies Department of Nursing NURS 410/411 Concept Map Project This assignment has a total point value of 100 and is worth 15% of your Assignment grade. Submit project on a PowerPoint. Students will present their patient on BB Collaborative Select a client for whom you have provided care to complete your project. The client should have both primary and secondary diagnoses to qualify for the study. Present the client’s profile including all pertinent demographic data. Identify and prioritize 3 nursing diagnoses. Describe the relationship among the primary and secondary diagnoses. Identify the five stressors: physiological, psychological, socioeconomic, cultural and spiritual. Construct a power point presentation to display all the medical diagnoses. This does not need to be an excessive PowerPoint, but you should be able to explain yourself well Display all nursing diagnoses in boxes around the circle, using arrows to show relationship among the diagnoses. Be sure to include relevant data to support the relationship among the primary and secondary diagnoses. This should include assessment data, lab data, and pharmacological agents. Describe the pathophysiology of each diagnosis. The map must be clear and concise. The update of the assignment. This does not need to be a concept map. Please put all pertinent information on the assignment. As stated below. The presentation should show your professionalism and knowledge regarding the management of your patient. Remember that the patient is an acute care patient. No risk for fall or Acute pain nursing diagnosis. Let the assessment, lab and diagnostic information guide your plan.
Bowie State University College of Professional Studies Department of Nursing NURS 410/411 Grading Rubric for Concept Map Project This assignment has a total point value of 100 and is worth 15 % of your grade. Submit this grading tool with your Concept Map Project Criteria Possible Points Your Grade Nursing and Medical Diagnoses Identify primary diagnosis and at least two secondary medical diagnoses. Identify and prioritize 3 nursing diagnoses 10 points __________ Data to Support Diagnoses Objective and subjective data that supports the nursing diagnoses chosen. (health assessment data) 5 points __________ Relationship between diagnoses Identify the relationship among the primary and secondary medical diagnoses 5 points __________ Physiological 5 points __________ Psychological 5 points __________ Socioeconomic 5 points __________ Cultural 5 points __________ Spiritual 5 points __________ 5 points __________ Diagnosis Variables Identify stressors for each of the following variables Client Patient Profile List all pertinent demographic data including age and sex Nursing Nursing Interventions with Rationale Identify 5 interventions for each nursing diagnosis. Be sure to support your rationale with references (text & journal articles). 10 points __________ Pharmacology Identify all pharmacological agents involved in the care of the client. 10 points __________ Pathophysiology Identify the physiology of primary and secondary diagnosis. Make sure that you explain the disease process and how the nursing diagnosis relates. 10 points __________ CONCEPT MAP 20 points __________ Effective communication Communicates medical diagnosis Power point should contain all information Clearly explains patient concerns and management Challenges peers (ask questions) Professional language utilized If you chose you may follow the information as presented below. Display all medical diagnoses in a circle at the center of your map. Display all nursing diagnoses in boxes around the circle. Be sure to include relevant data to support the relationship among the primary and secondary diagnoses. This should include lab data, pharmacology, and assessment data. Use arrows to show relationships among the diagnosis If you are missing pertinent labs of diagnostic studies, you should discuss expected studies which are needed. …
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