Instruction
Individual Care Map Week 4 Homework
This assignment is due as per the instructions and rubric in the syllabus supplement and in the folder for the Individual Care Map Assignment located in week 3.
Section 2 of your care map and write up is due in class in week 5 for entry to class. If you do not have it with you, you will be asked to leave while everyone else works on their care maps in class.
Use the Individual Care Map Case Study that you were assigned.
Bring a copy of the Care Map Template revised after feedback from week 4 along with the following components complete:
The priority problem-oriented nursing diagnosis correctly written with all three components.
Relationship links between the patient, data clusters, and priority nursing diagnosis
Answer the required prompts for the assignment (the last section on the care map template):
List ALL of the identified associated nursing diagnoses identified Section 1 and any that were added or revised. These should be written in the appropriate three-part or two-part format: “Problem” Related to “_____ “ Evidenced by “____” format.
Create a diagram showing how the listed nursing diagnoses were prioritized. The diagram should be inserted into the correct answer area in the paper
In the paper answer: Which problem-oriented physiological nursing diagnosis is most important to address with this client? Explain how this was determined. What was the method of prioritization?
Care Map Case Studies for Individual Assignments;
The students are assigned to the case study for R.L.:
R.L. is a 70 year old man weighing 165 lbs who lives by himself in an apartment. His spouse died 2 years ago and he has been managing independently until today. He normally drives himself to an elderly recreation center twice a week and socializes with friends. Today he was brought to the clinic by a neighbor who states, “I found him in the hall. Mr L is usually so nice!!” R.L. states, “You people aren’t helping me.” The nurse completes an assessment and records these findings: R.L.’s skin is warm.
Vital signs: Respiratory rate 18,
heart rate 96,
blood pressure 106/84,
temperature is 99.4 F orally and
oxygen saturation 97%.
His mucous membranes are dry, his lips are chapped, and he states, “I want a drink.” He is pulling away from the nurse during the assessment. The client states that he thinks he drank a coke earlier but doesn’t remember about anything to drink later in the day. He provides a urine sample that is very concentrated, clear, dark amber in color, and about 50 mL. He knows his name but not the day or the place.