Need help with concept map

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Hi, i need help with my concept map for the pt,Age 80 years old, weights 90 lbs, she is 5'9'. She was admitted with pnuemonia. She is living in a nursing home. she has a stage X ulcer covered with dry intact eschar. the ulcer is on the coccyx and is 10 multiply by 10 cm. Her left heel is intact but has a blue tinge. Patient has a history of PVD related to 60 years of smoking.. She quit 2 years ago when she entered the nursing home. She has no pedal pulses on her left foot. The foot is cool to touch. She is coughing up greenish thick sputum. She has decreased air entry to upper left lobe. she is complaining of being cold and asking for another blanket.IV 2/3 & 1/3 with 20 KCL at 100ml/hr in left hand. VS T 37 - HR 80- RR 24 Bp 130/90.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

what kind of help do you need? we are unable to create and post concept maps here on the public forums. you can see examples of nursing concept maps on this sticky thread: https://allnurses.com/nursing-student-assistance/care-maps-225330.html - care maps

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Hi,i understand that you are unable to make concept map,. I know that my cheif medical diagnosis is Pneumonia, but i dont know the 4 nursing diagnosis categories which i can segregate the data into. I tried to rationalise and came up with

Cheif Medical Diagnosis: Pneumonia

  • Patient has a history of PVD related to 60 years of smoking
  • She has decreased air entry to upper left lobe

  • She is coughing up greenish thick sputum

__________________________________________________________________________________

Nursing Dx #1: Impaired skin integrity r/t to immobility

  • she has a stage X ulcer covered with dry intact eschar. ulcer is on the coccyx and is 10 multiply by10 cm.

  • Her left heel is intact but has a blue tinge.

  • Patient has a history of PVD related to 60 years of smoking

___________________________________________________________________________________

Nursing Dx#2: Altered tissue perfusion :peripheral related to inadequate venous return and immobility.

  • She has no pedal pulses on her left foot.The foot is cool to touch.

  • she is complaining of being cold and asking for another blanket.

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Specializes in med/surg, telemetry, IV therapy, mgmt.

so, you need to come up with 4 nursing diagnoses. the idea behind doing a concept map is that it is supposed to help you organize all the information that you collect. you need to pull all the data from the scenario and put it into data boxes in your concept map that relate to the patient's chief complaint or other medical problems. she has:

  • pneumonia
  • history of pvd related to 60 years of smoking (quit 2 years ago)
  • stage x ulcer on the coccyx with dry intact eschar

all of the data in the scenario are related to these three medical conditions. that is where you will find the 4 nursing diagnoses. what you need to do is group the data. all nursing diagnoses are based upon the evidence that you have to support them. not all the data that was given is a problem. i don't know why her heel has a blue tinge to it. sounds like some kind of treatment is being done to it. that, however, does not make it an abnormal piece of data worthy of notation, in my estimation. nor is the fact that she is cold and asking for another blanket, that is a vague complaint. and so is the b/p of 130/90. it could be a symptom of the pvd. that leaves these remaining abnormal pieces of data:

  • respiratory
    • coughing up greenish thick sputum
    • decreased air entry to upper left lobe
    • rr 24

    [*]tissue oxygenation

    • no pedal pulses on her left foot and it is cool to touch
    • bp 130/90

    [*]nutrition

    • 5'9' and weighs 90 lbs

    [*]safety

    • 10 by 10 cm ulcer on the coccyx

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nursing dx #1: impaired skin integrity r/t to immobility

  • she has a stage x ulcer covered with dry intact eschar. ulcer is on the coccyx and is 10 multiply by 10 cm.
  • her left heel is intact but has a blue tinge.
  • patient has a history of pvd related to 60 years of smoking

how do we know that the etiology of this ulcer is because of immobility? the scenario doesn't say anything about the patient being immobile or not moving around. what it does say is that she has a history of pvd and smoking and a b/p of 130/90. what do we know years of smoking does to the circulatory system?

her left heel is intact but has a blue tinge. i think this is probably some kind of treatment being done. we often painted patient's heels with compounds to make them resistant to skin breakdown and that is probably what is going on here. the fact that the skin is intact means there is no breakdown. there is no infection that i know of that turns the skin blue.

patient has a history of pvd related to 60 years of smoking is just that, history.

this diagnosis should be listed as the last and 4th diagnosis since it involves safety. the skin is the patient's protection against invasion.

diagnosis: impaired
tissue
integrity r/t altered circulation and poor fluid and nutritional intake aeb a 10 by 10 cm ulcer on the coccyx

  • history of pvd related to 60 years of smoking

  • is 5'9' and weighs 90 lbs

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nursing dx#2: altered tissue perfusion, peripheral related to inadequate venous return and immobility.

  • she has no pedal pulses on her left foot. the foot is cool to touch.
  • she is complaining of being cold and asking for another blanket.

the etiology ("related to") part of this diagnosis must explain
why
the patient isn't getting oxygen and nutrients to, in this case, the peripheral tissues of her lower extremities. does it makes any logical sense that only the blood going away from the lower extremities would be inadequate (impaired)? venous blood normally carries de-oxygenated blood. when tissues are not being perfused they are not getting enough oxygen and nutrients from the arterial circulation--there is not enough arterial blood getting to them so the problem in pvd is inadequate arterial blood flow and usually venous flow as well. it can be stated very generically as "interrupted blood flow".

again, immobility was not mentioned in the scenario. also immobility is not a cause of
altered tissue perfusion, peripheral
. this diagnosis should be listed as the #2 diagnosis since it involves oxygenation and nutrition of the cells.

diagnosis: ineffective tissue perfusion, peripheral r/t interrupted blood flow aeb no pedal pulses in the left foot and left foot is cool to touch

  • history of pvd related to 60 years of smoking

  • no pedal pulses on her left foot and it is cool to touch

  • bp 130/90

  • she is complaining of being cold and asking for another blanket

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diagnosis: ineffective airway clearance r/t exudate and secretions in alveoli and bronchi and history of smoking aeb coughing up greenish thick sputum, decreased air entry to upper left lobe and respiratory rate of 24.

  • 60 years of smoking (quit 2 years ago)


  • coughing up greenish thick sputum


  • decreased air entry to upper left lobe
  • rr 24

this patient was admitted for pneumonia. this diagnosis should be listed as the #1 diagnosis since it involves breathing and the respiratory system.

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diagnosis: imbalanced nutrition: less than body requirements r/t inability to ingest food aeb patient is 5'9' and weighs 90 lbs

  • 5'9'


  • weighs 90 lbs


something is going on with this patient. at 5'9" she should weight much more and a normal weight for her can be found on several internet sites. this diagnosis should be listed as the #3 diagnosis since it involves food and fluid.

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