AUGUSTA UNIVERSITY - COLLEGE OF NURSING
CONCEPTUAL CARE MAP – NURS6700
Demographic Data
Student Name
Lee McFatridge
Nurse’s Name
Barbara
Tech’s Name Susan
Patient Initials DA Age 92_
Gender Female_ Room _808___Admission Date 1 1 / 1 3 _ _ Date of
Care 11/22
Height 170 cm Weight 7 0 . 3
Allergies
Tramadol, colchicine, morphine, nitroglycerin,
hydrochlorothiazide Religion
not specified
Code Status__DNR___ Isolation Y N Type
Diet__low sodium____Activity
assisted ambulatory
Chief Complaint and
Admitting Diagnosis
COVID 19 pneumonia
Community acquired bacterial
pneumonia
NCSBN: Step 1 Recognize Cues
Past Medical/Surgical History
Left foot cellulitis
Hyponatremia, likely due to dehydration
Essential hypertension
Subjective Assessment Data
Patient answers all questions
appropriately. Patient states she is
feeling much better and awaiting
discharge today. Denies any
complaints at this time.
Acquired hypothyroidism
Chronic A. Fib
Sick sinus syndrome status post pacemaker
Objective Assessment Data
IVs (sites & fluids), Drains, Tubes
Patient is sitting up in bed, alert and Has two saline locks. Both are 22 gauge.
oriented x4. Patient able to answer all One is placed in right forearm, the other is
placed in left forearm. Left IV site has
pertinent questions. Patient is able to
blood around injection/catheter and date
move all extremities with moderate shows it is expired per hospital protocol.
level of strength. Sensation to side of Nurse is notified of findings and will pull
cheek and arms within normal limits. this catheter.
Patient is ambulatory with assistance.
Patient does use a front wheel
walker. Pupils are PERRLA and
reactive pupils at 4 mm.
Skin is warm, dry, and intact. Multiple
bruises noted on both upper
extremities. Lower extremities have
pitted edema at less than 3 seconds
but does leave depressions for this
time. Left lower extremity is warm.
Right lower extremity is cool to the
touch. The nurse has been notified of
the findings and will contact the
physician.
NCSBN: Step 2 Analyze Cues
Diagnostic Tests
Priority Lab Values and
Abnormal interpretations
Priority Medications
Apixaban - Decreases risk of
stroke/systemic embolism associated with
nonvalvular atrial fibrillation.
Aspirin - Decreases platelet aggregation
Atenolol - Controls the patient’s
hypertension, decreasing the risk of stroke
and/or myocardial infarction.
Active Orders/Treatments
LPC/KEW 2021
See attached lab values. Many listed outside of normal
limits.
Patient has several abnormal lab values that show possible
liver issues.
Lab values should be Patient is being discharged with
rechecked due to
medication list. Further evaluation of
abnormalities from abnormal lab values is indicated.
yesterday.
CONCEPTUAL CARE MAP - NURS 6700
NCSBN: Step 3 Prioritize Hypotheses
Priority Nursing Diagnosis…Related To…As Evidenced By…
Activity Intolerance/Impaired Mobility related to patient having increased age, cardiac issues, and cellulitis in lower
extremities. Patient can ambulate but needs assistance in and out of bed in order to get to walker.
Supporting Subjective Data
Supporting Objective Data
Patient states although she can walk, she will need assistance Multiple bruises noted on both upper extremities possibly
getting out of bed and near her walker. She states she does due to bumping into objects. Lower extremities have pitted
become tired often while walking.
edema at less than 3 seconds but does leave depressions
for this time. Left lower extremity is warm. Right lower
extremity is cool to the touch.
Primary Outcome: Client Will…
(Must be patient-Specific, Measurable, Attainable, Relevant to nursing diagnosis, Time-specific--SMART)
Patient should be educated on the proper use of the walker and when/how to know when to rest when using. Mobility
and activity will be maintained at an optimal level for patient. Assess and monitor patient barriers to mobility and need
for assistive/adaptive devices. Assess patient's emotional response to limitations. Collaborate with interdisciplinary
team and initiate plans and interventions as ordered. Patient will walk some today taking breaks as needed to
strengthen and provide needed stamina.
Assessment
NCSBN: Step 4 Generate Solutions/Step 5 Take Action
Priority Interventions (Rationale)
Treatment and Medication(s)
Patient and Family Education
Patient does have cellulitis and states it Patient is on nonopioid analgesics and
is difficult to move lower extremities for uses assistive devices for ambulation.
longer lengths of time. Assessment for
patient long and short term pain goals
should be attempted with patient.
Goal is for patient to be more
mobile/ambulatory. Patient should be
educated on walk/rest procedures to
keep from becoming tired and also to
maintain absent pain or controlled at a
level of 4 or less.
NCSBN: Step 6 Evaluate Outcomes
LPC/KEW 2021
Evaluation: What is the overall status of client? Focus on the priority nursing diagnosis, describe the
patient’s status; improved? declined? unchanged? during your shift; provide supporting evidence.
Patient has improved since her hospital admission. With the pneumonia symptoms alleviated, patient is stronger and more
able to ambulate. However, the time bedridden from the infection has left her tired and some atrophy might be noted.
Patient is able to leave bed by herself and was assisted to the bathroom. Patient was willing to bathe herself with little
assistance. The patient understands and wants to be more mobile while decreasing any pain/neuropathy she might be
experiencing.
References
Piedmont EMR/EPIC
NANDA
LPC/KEW 2021