Pt # 3-Huber miller is 88yo &admitted to the medical unit with a diagnosis of pneumonia. He is widowed and lives in a skilled nursing facility. His granddaughter has the medical Power of attorney. He has dementia and CAD with CHF. He is confused and pulls off his o2 mask. He is sob with wheezing and o2 sats of 90% on 4lnc, His vital signs are stable and he has an iv infusing, He has fallen already once since admisssion. His orders are

)2 via nc at 4l, Duo neb ts every 6 hours for sob and wheezing

daily chest xraY ,

cbc and BMP

Falls risk precautions

IV D5 NS TKO

CL LIQ diet

Resp consult

Pt/OT consult

Upoob with waLKER

Digoxin 0.25 mg po daily

Xanax 0.25mg hs for agitation

Lopressor 50 mg po bid for htn and cad

Discharge planning to return to SNF

HE I

FOLLOWUP APPT IWTH PCP IN ONE MONTH

*****Part A: Using the above patient information, come up with a Concept map

– pick 3 of gordons patterns-state functional of dysfunctional/ (total of 3 boxes)

– Pick 2 nursing diagnoses for each gordons pattersn (total of 6 boxes)

– Pick 3 nursing interventions per diagnoses (total of 18 boxes)

Pick a goal or outcome

Subjective/objective /fill out template

Do writeup

References apa format

***** Part B:

Now please write a BRIEFpaper that explains your care map in words. This will show your thinking.Each Gordon’s Patterns box will be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that pattern. Then, move on to the next and make that a new paragraph. Don’t assume I know anything about your thought process, because I don’t. Show me how you are thinking!

Then answer these in the rest of the paper:

1. what were the identified nursing diagnoses and why? Remember to use the:

“Problem” Related to “_____“ Evidenced by “____” format.

2.Which nursing diagnosis is most important to address with this client? Explain how this was determined.

3. Which nursing diagnosis is second most important to address with this client? Explain how this was determined.

4. Which nursing diagnosis is least important to address with this client? Explain how this was determined.

à Then Complete the Nursing process by answering the questions below and including the information in the last paragraph: