Module 05 Assignment – Case Study Concept Map and Plan of Care
Example: Case Study Plan of Care and Concept Map
Case Scenario:
Mrs. J is admitted to the emergency department with a diagnosis of congestive heart failure. She was discharged from the hospital 10 days ago and comes in today stating, “I just had to come to the hospital today because I can’t catch my breath and my legs are swollen.” After further questioning, you learn that Mrs. J is strictly following the fluid and salt restriction ordered during her last hospital admission. Mrs. J reports gaining 1 to 2 pounds every day since her discharge.
Concept Map:
Identify two (2) priority nursing diagnoses for Mrs. J and develop a concept map to illustrate them (see example below).
Primary Medical Diagnosis:
· Congestive Heart Failure
Prioritized Nursing Dx# 2
· Fluid Volume Excess r/t fluid retention as evidenced by swelling
Prioritized Nursing Dx# 6
·
Prioritized Nursing Dx# 5
·
Prioritized Nursing Dx# 3
·
Prioritized Nursing Dx# 1
· Impaired Gas Exchange r/t fluid overload as evidenced by shortness of breath
Prioritized Nursing Dx# 4
·
Nursing Plan of Care
For each of the priority nursing diagnoses, establish one (1) goal. For each goal create two (2) nursing interventions.
Prioritized Nursing Diagnoses
Goal
Nursing Interventions
1. Ineffective Gas Exchange
Pt will maintain oxygen saturations greater than 95% during my shift
1. Give oxygen as ordered
2. Monitor clients oxygen saturations
2. Fluid Volume Excess
Pt will have decreased swelling in extremities by the end of my shift.
1. Administer diuretic as ordered
2. Monitor Intake and Output
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