CONCEPT MAP Randy Adams

.docx

School

Allegany College of Maryland *

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Course

206

Subject

Nursing

Date

Apr 29, 2024

Type

docx

Pages

3

Uploaded by ChefPorpoise3353

CONCEPT MAP - 8 Basic Needs STUDENT NAME: Allison Camacho Assessment and Nursing Diagnosis Patient Initials: __R.A. ____ OXYGENATION NUTRITION COMFORT- COMMUNICATION SAFETY NURSING DIAGNOSIS (# in Priority) ELIMINATION TEACHING PSYCH/SOCIAL I don’t know how this fits with the concepts. #1 Ineffective breathing if in a stressful situation/nightmare. Guide patient to complete relaxation techniques such as deep breathing exercises Nursing Diagnosis: Impaired gas exchange r/t anxiety #4 #2 Appetite adequate for patient. Offer high calorie, high protein, easy to grab snacks and meals because the patient may be distracted with stress. Nursing Diagnosis: Risk for imbalanced nutrition less than body requirement r/t anxiety Pt c/o trouble sleeping and nightmares. Provide reassurance and comfort. Provide measured to assist patient with relaxing. Nursing Diagnosis: Disturbed sleep pattern R/T PTSD Reason for seeking healthcare: Medical Diagnosis/Surgical Procedure Follow up from car accident and signs of post- traumatic stress disorder. PRIORITY ASSESSMENTS: Ensure safety, assess coping strategies, PTSD screen, ACE, mini cog, assess and help eliminate symptoms related to PTSD. #6 Anxious in social situations, reports looking for exits. Provide patience, support, and flexibility, practicing therapeutic communication while also encouraging the patient to communicate. Nursing Diagnosis: Disturbed thought process r/t difficulty concentrating. #3 Pt reports anxiousness, trouble sleeping, nightmares, and sensitivity of light and noise. Suggest a calming environment to help relieve fear and anxiety. Nursing Diagnosis: Fear r/t perceived threat or danger #8 Elimination not assessed #5 #7 Educate patient on PTSD including possible symptoms and treatment. Nursing Diagnosis: Knowledge Deficit r/t PTSD C/O anxious, nervous about questions/assessment. Recommend and encourage speaking with a support group and engaging in social interaction with other like- minded people such as other veterans. Nursing Diagnosis: Ineffective coping r/t situational crisis, fear, and uncertainty.
Pt is a 32-year-old male who is dealing with the aftermath of an accident. The primary problems identified include PTSD complicated by a traumatic brain injury (TBI), with primary assessments in neurology and psychology. The nursing diagnoses outlines in the concept map are (#1) Impaired gas exchange r/t anxiety and ineffective breathing in a stressful situation. (#2) Disturbed Sleep Pattern r/t PTSD; pt expressed his trouble sleeping and nightmares. (#3) Fear r/t perceived threat or danger, pt reports anxiousness, trouble sleeping, nightmares, and sensitivity of light and noise. (#4) Risk for imbalanced nutrition less than body requirements r/t anxiety; Plan to offer and educate on proper diet/nutrition such as diet high in calorie and high in protein as well as easy to grab snacks and meals on the go because patient may be distracted with stress and anxiety. (#5) Ineffective coping r/t situational crisis, fear, and uncertainty; Pt c/o anxiousness and nervous about questions/assessment. Will provide resources and recommend/encourage speaking with a support group and engaging in social interaction with like- minded people such as other veterans. (#6) Disturbed Thought process r/t difficulty concentrating; Pt admits he is anxious in social situation, and reports looking for exits. (#7) Knowledge deficit r/t PTSD; plan to educate pt on PTSD including possible symptoms and treatment. Will continue to ensure patient safety, assess coping strategies, and help eliminate symptoms related to PTSD. The goal is for Randy to list three resources by the end of the shift that he would be interested in participating in. This concept map provides a comprehensive plan for addressing Mr. Adams’ complex needs, focusing on both physical and psychological aspects of his recovery.
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