CONCEPT MAP HELP pleaaaase =)

[EricaLynn<3]

I really need some help coming up with 2 problems/diagnosis to make a concept map for my patient! Ive been doing real well with coming up with problems but for some reason i am completely stumped

My patient is a 76 year old male who was having thanksgiving dinner when all the sudden he lost sight in both eyes lasting longer then 10 minutes, he had severe diaphoresis, and then a large explosive BM...he was brought to the hospital and they diagnosed him with ICH (intracerebral hemmorhage) and later found the specifics in that it was an acute SDH (subdural hematoma). The reason for his SDH is from his chronic use of anticoagulants d/t mechanical valve replacement

hx: mechanical aortic valve and mitral valve replacement

CABG x8 followed by a CABG x3 3 years later

perm. pace

chronic kidney disease

ischemic CMP with EF 40-50%

typeII diabetes, insulin dependent

neuropathy

nephropathy

COPD on home o2 2L

PVD

embolic stroke in previous year

dyslipidemia

hypothyroidism

a-fib

ifff you could help me come up with 2 problems - related to.... that would be amazing!!

thanksss so much for your help!:redbeathe

[Daytonite, BSN, RN]

you've done a wonderful job of listing his medical history. however, you are trying to come up with a nursing plan of care. that is dependent upon the assessment data that you discovered. where is that information? since this patient had a subdural hematoma, where is your neural assessment of this man? where did he fit on the glasgow scale? is he awake? alert? moving? talking? breathing on his own? what is his heart doing now? lung sounds? where is that information? with all his medical problems you should have a long list of data you collected from your physical exam. that data is what is going to lead you to 2 nursing problems (nursing diagnoses). every nursing diagnosis has a list of defining characteristics (signs and symptoms) just as every medical diagnosis has a list of signs and symptoms. the nice thing about doing care plans by concept mapping is that the concept map helps make this very clear to you.