Hospital Concept Map, Coursework Example

Reason for Admission/Medical Surgical Diagnoses:

Transient Ischemic Attack (G45.9), Slurred Speech (R47.81), Hypertension (I10)

 Focused Assessment:

• 79-year-old female presently in hospital with transient ischemic attack, slurred speech and hypertension.
• Cardiomyopathy
• Peripheral neuropathy
• Asthma
• Physical examination (musculoskeletal, skin)

Goals:

Short Term:

-Pain prescription will be administered to the patient to minimize pain

-Radiographic (MRI) imaging to tell the severity and state of the injury.

-Surgery to remove born fragments, decompress and stabilize.

-full code resuscitation

Long Term:

Fixing the neck/head brace

#__:  Concept: medication

Related Data:

Cardiac, cardiomyopathy and heart problems

Interventions:

Pacemaker and heart monitoring, administering blood pressure

#__:  Concept: Infection

Related Data: 

Cellulitis

Interventions: 

Administer antibiotics

#__:  Concept: Oxygenation

Related Data: 

Low EF, shallow breathing patterns

Interventions:  

Putting the pt in a ventilator, examine sounds from the heart and the lungs (Auscultate), Continuous Positive Airway Pressure, to keep airways open, oxygen administration, elevation of the head bed. Measure respiratory acidosis

#__:  Concept: Pt education

Related Data: 

Inability to move about, inability to carry out normal activities, difficulty in speech

Interventions:  

Physiotherapy, occupational therapy, counseling, speech therapy