Healthcare 640 - Care Map Final

Healthcare 640 – Care Map Final

Assessment: 10/24

Subjective Data: 10/24

Neuro/Sensory

Pt. stated pain (8/10) when trying to move in bed.

Genitourinary

Pt stated he voided at 5:30am. Pt. had an output of 100mL.

Gastrointestinal

Pt. stated his last bowel movement was last night.

Objective Data: 10/24/2016

Neuro/Sensory	Pt. was alert, awake, and oriented to person, place and time. Pt. had difficulty moving in bed.
Cardiovascular	BP=124/79; HR 63 Temp= 97.4 O2 Sat=93 RR= 14 Regular heart rate and rhythm S1, S2 no murmur Pacemaker
Respiratory	Nasal Cannula 2L. Signs of SOB Increased Sputum production Wheezing noted on anterior lobes. Posterior lobes are clear upon auscultation.
Integumentary	Reddeness on the back. Pale skin color.
Gastrointestinal	Heart health diet Abdomen soft and rounded Hyperactive BS.
Musculoskeletal	Pain 8/10 on the back. The duration is 20 minutes that is aggravated with movement. 1 max assist for ambulation MAE 3/5 strength on all quadrants. High fall risk

Nursing Diagnosis List

Physiological

Impaired gas exchange related to decreased ventilation perfusion aeb shortness of breath, pale skin color and increased sputum production.
Ineffective breathing pattern related to shortness to breath, mucus bronchoconstriction aeb decreased oxygenation.
Ineffective airway clearance related to increased secretion in bronchi and obstructed airway aeb hypoxemia and dyspnea.
Chronic pain related to compression fracture of T4, L5 aeb patient stating pain of 8 on a scale of 1-10 and pain that intensify when moved.
Risk for fall related to compression fracture T4, L5.
Activity intolerance related to imbalance between oxygen demand and supply aeb shortness of breath, pale skin color and use of supplementary oxygen.
Risk for infection related to inability to clear secretion.
Anxiety related to lack of control over progression of symptoms aeb patient states. “ I don’t know how to keep my symptoms from flaring up.”

Psychosocial

Ineffective coping related to patient’s anxiety and decreased level of activity aeb patient states, “ I can’t get anything done without worrying about getting sick.”

Educational

Knowledge deficit: Health promoting behavior related to exacerbation of symptoms and lack knowledge of combining factors aeb patient states he was not aware that his diagnosis would cause other problems in his life.

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