“ four ” prioritized interventions W r i t i n g
CONCEPT MAP PAPER : DUE December 9, 2021 BY 11:59 PM
You will randomly select a patient from V Sim during class on 11/30/21 which you will use the patient to complete the Concept Map Assignment
FOR THIS PAPER YOU ARE EXPECTED TO:
? USE A HOLISTIC APPROACH TO DEVELOP A SCENARIO BASED ON YOUR ASSIGNED RESIDENT’S ADMITTING, CURRENT, AND ONGOING HEALTH ISSUES
? USE THE CONCEPT MAP FORMAT POSTED NO SUBSTITUTIONS (THERE IS A SAMPLE MAP WITH LEGEND IN THE FOLDER)
? ONLY USE ONE NANDA PER PAGE JUST LIKE THE STUDENT EXAMPLE (YOU SHOULD HAVE 4 OF THESE PAGES TO FULFILL NANDA REQUIREMENTS)
? FOUR INDIVDUALIZED PRIORIZED NANDA(S)
? REMEMBER, YOUR ASSIGNED RESIDENT HAS ACTUAL PROBLEMS AS OPPOSED TO JUST POTENTIAL AND RISK FOR
? NO LESS THAN “FOUR” PRIORITIZED INTERVENTIONS FOR EACH NANDA
? PLEASE INCLUDE YOUR NURSING GOALS FOR EACH NANDA (1 LONG-TERM AND 1 SHORT-TERM)
Location: Neurological Unit 0800
SBAR report from the night nurse:
Situation: Mr. Russell is a 55-year-old Native American male who was admitted with a stroke with mild left hemiplegia yesterday afternoon. He had a head CT and received thrombolytic therapy in the ED. He is nothing by mouth except for medications until the speech therapist has completed a bedside evaluation, which is scheduled for later this morning. He is scheduled for physical therapy later today.
Background: Mr. Russell has a history of hypertension, coronary artery disease, and diabetes mellitus type 2. He has smoked over a pack of cigarettes per day for the past 35 years and does not exercise.
Assessment: We have already checked his blood glucose level this morning. His vital signs have been stable and he slept well last night. He was able to get up to go to the bathroom with the use of a walker. His neurological checks are stable and he continues to have mild left hemiplegia. His hand grasps are almost equal but a little weaker on the left side. His pupils are equal and react to light. Swallow reflex is intact. He is oriented x3. I have already done a Morse Fall Risk assessment with a total high risk score of 60.
Recommendation: You should do a vital signs assessment, perform a neurological assessment, and talk about safety with Mr. Russell. You should also provide patient education on risk and prevention of aspiration. His morning medications are up and should be administered.