Concept map diabetes mellitus type 2

You are caring for a 58-year-old gentleman working as a lawyer, with known history T2DM for 10 years, systemic hypertension, and dyslipidemia. He is on tablet metformin 1 g twice daily, tablet glimepiride 4 mg twice daily, tablet sitagliptin 50 mg once daily, tablet telmisartan 40 mg once daily, and tablet atorvastatin 10 mg bedtime. His biochemical evaluation shows fasting glucose of 210 mg/dl,postprandial plasma glucose of 280 mg/dl, and HbA1c of 8.5%. Patient also complains of feeling “lighted headed,” thirst, hunger, and increased urination. Vital signs BP 150/100, P 80, R 12, Temp. 98.6SPO2 99% on room air. NURSING PROCESS PAPERS: CONCEPT MAPPING The Nursing Process: Assessment, Nursing Diagnosis, Goals, Interventions, and Evaluation. PREPARATION: ASSESSMENT PHASE. • Gather clinical data: assess the patient; review the patient records, laboratory data, medications, and treatments. Objective and subjective data are important. STEP 1: DEVELOP A BASIC SKELTON DIAGRAM (See Example #1) • Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care. • In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis). • Around this central diagnosis, arrange general problems (nursing diagnoses) that represent your patient’s responses – actual or potential - to this reason for seeking health care (usually the medical diagnosis). • Recognize major problem areas. (You do not have to state the nursing diagnosis yet.) STEP 2: ANAYZE & CATEGORIZE THE DATA (See Example #2) • Identify and group clinical assessment data, treatments, medications, medical history data, and diagnostic and laboratory test data related to the general problems (nursing diagnoses). This provides support for the nursing diagnoses. • Data can be listed in more than one area if it is relevant to more than one category. • If you do not know where the data should go but you think it is important, list it off to the side of the map and check with your clinical professor. • Finally, determine the priority nursing assessments that still need to be performed regarding the primary reason for seeking care (medical diagnosis); write them in the box at the center of the map. STEP 3: ANALYZE NURSING DIAGNOSES RELATIONSHIPS (See Example #3) • Draw lines between nursing diagnoses to indicate relationships. • Label the general problems you have identified according to the North American Diagnosis Association (NANDA) classification system. STEP 4: IDENTIFY GOALS/OUTCOMES & NURSING INTERVENTIONS (See Example #4) • On a separate piece of paper, for each nursing diagnosis write your patient goals/outcomes. • Goals/outcomes are specific, realistic, and measurable. They are usually written in the future tense, “The patient/client will. …” • List nursing interventions to attain the goal/outcome. Interventions are specific nursing orders and are directly related to the goal. Interventions must be written within the domain of nursing (not physicians). Interventions include what you are carefully monitoring, treatments, patient education, and medications. • Be complete and think, “What am I doing this day for this patient/client”. • Carry the Concept Map and list of interventions with you as you work with the patient. Either check off interventions as you complete them or make revisions in the diagram and interventions during the day. STEP 5: EVALUATE PATIENT’S RESPONSES (See Example #4) • As you complete a nursing intervention, write down the patient’s responses. • This step also involves writing your clinical impression regarding your patient’s progress toward expected goals/outcomes and the effectiveness of your interventions to bring these goals/outcomes about. Did you meet the goal or not? Concept Map Directions 1 SAMPLE PATIENT for Nursing Process Paper: Concept Mapping Your patient for today is W. C., a 76-year-old male who was admitted 4 days ago with an abdominal abscess and bowel obstruction. He went to the operating room for an Exploratory Laparotomy two days ago. He has a history of DM Type 2, Cancer of the lung 2 years ago that was treated with radiation and chemotherapy, an enlarged prostrate, Cancer of the bone with chronic bone pain in his right leg, and Atrial Fibrillation with a pulse rate of 128 and irregular. He has 2 abdominal drains with purulent drainage and a temp of 100.5 F. Currently he is NPO with a NG tube to suction. He has an IV of D5 RL at 100 mL/hr. He has decreased breaths sounds on the right lower lung field and is on Oxygen at 6L by mask. He has a Foley catheter in place. He says he is nervous; clenching his fists, and says that he is afraid of dying. Medications: PCA with Morphine, Digoxin, Kefzol, Ventolin inhaler, Proscar, and Regular Insulin by sliding scale. STEP 1: DEVELOP A BASIC SKELETON DIAGRAM (Example #1) • • • Based on the clinical data you have collected, begin a concept map care plan by developing a basic skeleton diagram of the reasons your patient needs health care. In the middle of a blank piece of paper, write the patient’s reason for seeking health care or hospitalization (usually a medical diagnosis). Around this central diagnosis, arrange general problems (nursing diagnoses) that represent your patient’s responses to this reason for seeking health care (usually the medical diagnosis). Recognize major problem areas.