92 – years old female who was admitted to the hospital after she had a fall. She took a step and then loss her balance falling striking her right hip. The chief is fall hip fracture.
Patient with past medical coronary artery disease. End -stage renal disease. Hypertension. Hypothyroidism.
Patient vital sign is T=37.1, Bp=164/63. HR =79. RR=18
Base on patient information. Please help me do concept map base on rubric below
- HISTORY- information is complete and appropriately connected to related parts
2. DIAGNOSTIC DATA- relevant lab tests and results provided and related/connected within CM
3. COMPLETE HEAD TO TOE ASSESSMENT- assessment elements/applicable data connected to relevant problems
5. INDIVIDUALIZED POC- top 3 diagnoses are prioritized in appropriate order; problems written as nursing diagnosis to include contributing factors; measurable goals are connected to diagnosis and interventions; interventions are clear, patient specific, problem solving included, realistic, independent and collaborative interventions, including patient education; outcomes reflect the nursing diagnosis are measurable, time and framed and include long and short term goals; evaluation reflect patient response, progress, regress
6. COMMUNICATION-logical and concise schematic representation; components are connected and related to one another in a logical fashion reflecting strong critical thinking, include key, NO LISTS WITHIN BOXES OR SHAPES
7. MEDICATIONS-pertinent meds with brief usage applying to identified only AND assigned patient, include all scheduled meds (consult with your instructor on reoccuring routine hospital meds like stool softenoers and probiotics AND prns)
8. PATHOPHYSIOLOGY- one sentence long described within nursing and medical diagnosis