Need Advice on Concept Map

[mickle]

I've spent at least 5 hours flailing around with this. I'm not asking for an answer, but any explanation or direction would be appreciated.

This is my second concept map for my second clinical day.

I have been assigned HTN as the medical dx. I need to come up with a nursing problem (since I'm a student) related to HTN for a pt whose HTN is already successfully controlled with a calcium channel blocker and a beta blocker. Pt is in the late stages of AD in a nursing home. Has pressure sores R & L trochanter - stage 1. Right arm in contracture. (If I work very slowly I can extend it a little.) Pt has said "I don't want to eat" and makes it clear doesn't like being turned. Did a poor assessment last visit. Pt nurse said should be starting on hospice as pt is anorexic. BMI is 17, but pt is skin & bones. Pt also has DM.

Anyway, I'm in a quandary because her HTN is controlled, but I still need to come up with a nursing dx (problem), related problem and 8 interventions on this concept map related to HTN.

The 4 nursing dx in Ackley for HTN don't seem to apply:

1) Disturbed Energy Fields - not qualified to determine or intervene

2) Imbalanced Nutrition - more than body requirements (she is anorexic)

3) Ineffective Health maintenance - duh, she is in late stages of AD

4) Noncompliance r/t side effects of tx, lack of understanding regarding importance of controlling HTN - She is in a nursing home being cared for so this doesn't seem applicable either.

I'm tempted to just come up with a plan following Ackley even though it doesn't apply and then do one that addresses either tissue perfusion (did that last week for DM), so don't think it will be well received by CI a second time or go way out on a limb and search for how anorexia (imbalanced nutrition: less than body requirements or Adult Failure to Thrive) might be related somehow to HTN or a threat to the effectiveness of her HTN meds.

Plan to spend more time on the pathophys of HTN and her drugs and see if I can weave something together.

Anyway, insight or encouragement would be appreciated. Already met with another classmate who was also assigned HTN w/ a pt in similar situation (except completely non-verbal) and we wasted 2 hours trying to figure out a way to make the rote use of Ackley work for us.

We can't use any "risk for" dx either.

Anyway, I'll check back tomorrow.

[Daytonite, BSN, RN]

there is no nursing diagnosis for hypertension. hypertension is a medical diagnosis. we nurses deal with problems that patients have that revolve around their response to their health conditions. we have been given the nursing process as a tool to help us in care planning which is nothing more than determining the patient's nursing problems and developing strategies to do something to either improve the problem, stabilize it, or support its deterioration. the steps of the nursing process as they apply to care planning are as follows:

1. assessment (collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
   
   • a physical assessment of the patient
     
   • assessment of the patient's ability and any assistance they need to accomplish their adls (activities of daily living) with the disease
     
   • data collected from the medical record (information in the doctor's history and physical, information in the doctor's progress notes, test result information, notes by ancillary healthcare providers such as physical therapists and dietitians
     
   • knowing the pathophysiology, signs/symptoms, usual tests ordered, and medical treatment for the medical disease or condition that the patient has. this includes knowing about any medical procedures that have been performed on the patient, their expected consequences during the healing phase, and potential complications. if this information is not known, then you need to research and find it.
     
     • use: https://allnurses.com/forums/f205/medical-disease-information-treatment-procedures-test-reference-websites-258109.html - medical disease information/treatment/procedures/test reference websites
       

[*]determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use). it helps to have a book with nursing diagnosis reference information in it. there are a number of ways to acquire this information.

• your instructors might have given it to you.
  
• you can purchase it directly from nanda. nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international. cost is $24.95 http://www.nanda.org/html/nursing_diagnosis.html
  
• many authors of care plan and nursing diagnosis books include the nanda nursing diagnosis information. this information will usually be found immediately below the title of a nursing diagnosis.
  
• the nanda taxonomy and a medical disease cross reference is in the appendix of both taber's cyclopedic medical dictionary and mosby's medical, nursing, & allied health dictionary
  
• there are also two websites that have information for about 75 of the most commonly used nursing diagnoses that you can access for free:
  
  • http://www1.us.elsevierhealth.com/evolve/ackley/ndh7e/constructor/
    
  • http://www1.us.elsevierhealth.com/merlin/gulanick/constructor/index.cfm
    

[*]planning (write measurable goals/outcomes and nursing interventions)

• goals/outcomes are the predicted results of the nursing interventions you will be ordering and performing. they have the following overall effect on the problem:
  
  • improve the problem or remedy/cure it
    
  • stabilize it
    
  • support its deterioration
    

  [*]interventions are of four types

  • assess/monitor/evaluate/observe (to evaluate the patient's condition)
    
    • note: be clear that this is assessment as an intervention and not assessment done as part of the initial data collection during step 1.
      

    [*]care/perform/provide/assist (performing actual patient care)

    [*]teach/educate/instruct/supervise (educating patient or caregiver)

    [*]manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

[*]implementation (initiate the care plan)

[*]evaluation (determine if goals/outcomes have been met)

the diagnoses listed in ackley/ladwig are merely suggestions. read the title page of this cross index and it clearly says that. the steps of the nursing process still need to be followed in order to customize the care. also read section i of the ackley/ladwig book which explains how the nursing process is used to plan care.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• htn
  
• late stages of ad
  
• dm
  
• anorexic (per nurse)
  
• stage i pressure sores r & l trochanter
  
• right arm contracture
  
• medical treatment:
  • calcium channel blocker
    
  • beta blocker [in addition to lowering the blood pressure these have depression as a side effect which you can argue is contributing to the dementia of the ad and making it worse. it is probably also fatiguing the patient which could arguably be contributing to their inability to maintain their adls]

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data

• "i don't want to eat"
  
• bmi is 17
  
• "skin & bones"
  
• doesn't like being turned

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use

• adult failure to thrive r/t cognitive and memory deficits secondary to alzheimer's disease aeb bmi of 17, refusal to eat, appearance of looking like "skin and bones", and resistance to care.
  
• impaired physical mobility r/t neurological impairment and disuse aeb [description of rom inability of right arm]
  
• impaired skin integrity r/t immobility and pressure over bony prominences aeb [description of skin over r & l trochanter]