Cocept-Map-Case Study

Case Study of Concept Map

The concept map that was developed for the Patient J. H. was based on the diagnosis that was conducted on his condition, based on the incident experienced at the restaurant, whereby the patient had experienced fall. For determining the appropriate treatments and interventions that must be provided for proper recover of the patient, a thorough check up of the overall health and body was conducted and based on the assessment, the Gordon’s patterns were determined. The first Gordon Pattern and cluster data was based on the Health Perception Management, whereby the factors that were considered were the PCP visit, which was normal and the practice of taking medication as has been prescribed. These were all Functional with respect to Gordon’s pattern.

With respect to the next set of Gordon’s Patterns set, the diagnosis was based on Activity – Exercise. This was determined based on the findings of the diagnosis that offered insights such as weakness in the left leg of the patient, confusion, and shortness of breath, thereby leading to belief that is a dysfunction.

The third set of Gordon’s Patters was Elimination based on the gastrointestinal aspects such as soft and non distended abdomen, with no GI symptoms, thereby rendering the decision of it being functional.

The fourth set of Gordon’s Pattern was Nutritional: Metabolic and the same was decided on the factors, diabetes, dryness of skin, thereby rendering it to be a dysfunction.

The last set of Gordon’s Pattern was Cognitive and the basic symptoms were the difficulty in hearing, wears glasses, there providing the insight of it being early onset of dementia and hence was a dysfunction.

 

 

 

 

  1. In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped you.)

The first Gordon Pattern and cluster data was based on the Health Perception Management, whereby the factors that were considered were the PCP visit, which was normal and the practice of taking medication as has been prescribed. These were all Functional with respect to Gordon’s pattern.

With respect to the next set of Gordon’s Patterns set, the diagnosis was based on Activity – Exercise. This was determined based on the findings of the diagnosis that offered insights such as weakness in the left leg of the patient, confusion, and shortness of breath, thereby leading to belief that is a dysfunction.

The third set of Gordon’s Patters was Elimination based on the gastrointestinal aspects such as soft and non distended abdomen, with no GI symptoms, thereby rendering the decision of it being functional.

The fourth set of Gordon’s Pattern was Nutritional: Metabolic and the same was decided on the factors, diabetes, dryness of skin, thereby rendering it to be a dysfunction.

The last set of Gordon’s Pattern was Cognitive and the basic symptoms were the difficulty in hearing, wears glasses, there providing the insight of it being early onset of dementia and hence was a dysfunction.

 

  1. Using Gordon’s as a guide, Explain which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph).

The nursing diagnosis were determined on the basis of the sets of Gordon’s Patterns and these include the following.

Physiological  Nsg Dx: Risk of fall due to weakness in left leg. With the goal of Patient will not sustain fall by the end of the shift and during the stay. The Intervention and rationale were: Remove hazardous things that can hurt the patient while movement and decrease chance of fall, Assessing the environment of the patient, and Providing mobility devices. The Evaluation was that the Patient did not fall during the shift.

Psychosocial  Nsg Dx: Dementia and Denies pain. With the goal Patient shall be able to accept the pain and realize the episode of dementia. The Intervention and rationale were Guide the patient through the process that allows them to realize the pain, Help the patient understand the aspects of dementia that has been forcing the act of denying pain. The Evaluation was that the Patient was able to recognize and accept pain.

Educational  Nsg Dx: Risk of fall due to weakness in left leg. With the goal Promoting safety precautions to be used by the patient while walking to prevent fall. The Intervention and rationale were to Position personal items within reach and place call bells to assist during movement, to Position bed in lowest so that the patient moves without difficulty and Turn on bed alarm so as to notify or alert the staff when the patient attempts to wander. The Evaluation was the Patient seek assistance for movement and did not fall during the hospitalization period.

  1. List the identified nursing diagnoses in priority order the:

“Problem” Related to “_____  “ Evidenced by “____” format.

Risk of fall due to weakness in left leg

  1. Which nursing diagnosis is most important to address with this client? Explain how this was determined.

The nursing diagnosis that the patient had syncope was most important as the patient had experienced fall at the restaurant.

  1. Which nursing diagnosis is second most important to address with this client? Explain how this was determined.

The second most important is the diagnosis that the patient has diabetes and the same is affecting dementia as well. This was determined from the diagnosis that the patient denied pain.

  1. Which nursing diagnosis is least important to address with this client? Explain how this was determined.

The hearing loss is of least importance as the same develops with the maturity of age.

  1. Describe the evaluation of the client for each nursing diagnosis?

Goals met, Mr. J. H. did not fall during the shift

Goals met, Mr. J. H.was able to recognize and accept pain

Goals met, Mr. J. H.seek assistance for movement and did not fall during the hospitalization period

 

 

References

Gordon, M. (2014). Manual of nursing diagnosis. Jones & Bartlett Publishers.

DiCenso, A., Guyatt, G., &Ciliska, D. (2014). Evidence-Based Nursing-E-Book: A Guide to Clinical Practice. Elsevier Health Sciences.