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Rasmussen College Concept Map Nursing Diagnosis: Short Term Goal: Long Term Goal: Clinical Manifestations: Subjective: Objective: Evaluation of Plan or Anticipated Evaluation of Plan: Nursing Interventions (at least 4): Collaboration: With whom will the nurse be working and why? Patient’s Laboratory & Test Results: Patient’s Past Medical History and Significant Findings: Patient’s Medical Diagnosis

Paper For Above instruction

This paper presents a comprehensive nursing care plan utilizing a concept map approach, focusing on a specific patient diagnosis, associated clinical manifestations, and targeted interventions. The objective is to develop an effective framework for patient-centered care that addresses short-term and long-term goals through detailed assessment, strategic planning, and interdisciplinary collaboration.

Introduction

Creating a structured nursing care plan involves understanding the patient's medical diagnosis, assessment of clinical manifestations, setting both short-term and long-term goals, and implementing appropriate interventions. A concept map serves as an excellent visual tool to organize these elements systematically, ensuring comprehensive and cohesive patient care. This paper demonstrates the development of such a plan based on a typical patient scenario, integrating nursing diagnoses, clinical assessments, and collaboration with healthcare team members.

Nursing Diagnosis

The nursing diagnosis selected is "Ineffective Airway Clearance," which is common in patients experiencing respiratory difficulties. This diagnosis is substantiated by clinical manifestations such as labored breathing, productive cough, and decreased oxygen saturation levels. Recognizing the nursing diagnosis helps to prioritize interventions aimed at improving airway patency and oxygenation.

Clinical Manifestations

Subjective data include the patient reporting shortness of breath, chest tightness, and fatigue. Objective data encompass observable signs such as increased respiratory rate, use of accessory muscles, wheezing on auscultation, and decreased oxygen saturation on pulse oximetry. These manifestations guide the nurse in assessing the severity of airway compromise and evaluating the effectiveness of interventions.

Goals

Short-Term Goal

The patient will demonstrate effective airway clearance within 24 hours through improved breathing patterns, reduced coughing, and stabilized oxygen saturation above 92%.

Long-Term Goal

The patient will maintain optimal respiratory function and demonstrate understanding of disease management strategies, minimizing the risk of future respiratory complications over the next three months.

Assessment and Data Collection

Initial assessment involves gathering subjective information like patient's perceived breathing difficulty and objective data including vital signs, auscultation findings, and laboratory results such as arterial blood gases (ABGs). Past medical history revealing prior respiratory illnesses or chronic conditions influences ongoing care planning.

Evaluation of Plan

The effectiveness of nursing interventions will be evaluated based on clinical improvement, patient feedback, and laboratory results. Success is indicated by stabilized vital signs, improved oxygenation, and patient reports of eased breathing. Adjustments in the care plan are made accordingly to optimize outcomes.

Nursing Interventions

1. Administer prescribed bronchodilators and mucolytic agents to facilitate airway clearance.
2. Encourage deep breathing exercises and effective coughing techniques.
3. Provide supplemental oxygen as needed to maintain oxygen saturation above 92%.
4. Position the patient in an upright or semi-Fowler's position to maximize lung expansion.

Collaboration

The nurse collaborates with physicians, respiratory therapists, and pharmacists to coordinate medication administration and inhalation therapies. Respiratory therapists assist with airway management and oxygen therapy, while physicians evaluate the need for further diagnostics or interventions based on patient response.

Laboratory and Test Results

Laboratory findings include arterial blood gas analysis showing hypoxemia or hypercapnia. Chest X-rays reveal infiltrates or obstructions. Pulmonary function tests provide information on airflow limitation, aiding in diagnosis and management.

Past Medical History and Significant Findings

The patient's history includes asthma or chronic obstructive pulmonary disease (COPD), previous respiratory infections, or smoking history, which influence current management strategies and risk assessment.

Medical Diagnosis

The primary medical diagnosis is "Acute Exacerbation of COPD," which necessitates prompt interventions to alleviate symptoms, prevent complications, and promote respiratory recovery.

Conclusion

Developing a detailed nursing care plan with a concept map facilitates a holistic approach to patient management. By integrating comprehensive assessment data, clear goals, evidence-based interventions, and interdisciplinary collaboration, nurses can significantly improve patient outcomes and support recovery. Continual evaluation ensures interventions remain effective, and plans are adjusted to meet evolving patient needs.

References

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