Concept Map

In: Other Topics

Submitted By kmantonio
Words 288
Pages 2
Patient’s Initials: D., M.L.R. | Chief Complaint: Fever | Age: 31Y | Gender: Male | Basis for Prioritization: Maslow’s Hierarchy of Needs | Category: III | Room No.: 869 | Date Admitted: November 22, 2012 | Student Nurse: ANTONIO, Karla Mae D. |
NDx#2: Risk for ineffective breathing pattern related to inflammatory process
Objective Cues:
Vital Signs of RR=20 cpm Temp=39.1C HR=70 bpm BP=130/80 mmHg
Shivering
Clear breath sounds
No difficulty in breathing
Non- productive coughing
CBC result: Hematocrit, Hemoglobin, RBC below normal count.
Medications: Rocephin vial 1 gm
Omepron Capsule 20 mg
Zithromax tablet 500 mg

NDx#1: Hyperthermia related to inflammatory process as evidenced by temperature of 39.1 C
Subjective Cues:
“Nararamdama ko na nilalagnat nanaman ako, medyo nilalamig na ako” as verbalized by the significant other.
Objective Cues:
Vital Signs of RR=20 cpm Temp=39.1C HR=70 bpm BP=130/80 mmHg
Shivering
Clear breath sounds
No difficulty in breathing
Non- productive coughing
CBC result: Hematocrit, Hemoglobin, RBC below normal count.
Medications: Rocephin vial 1 gm
Omepron Capsule 20 mg
Zithromax tablet 500 mg
Paracetamol every 4 hours

NDx#3: Risk for impaired gas exchange related to alveolar capillary membrane changes secondary to inflammation.
Objective Cues:
Vital Signs of RR=20 cpm Temp=39.1C HR=70 bpm BP=130/80 mmHg
Shivering
Clear breath sounds
No difficulty in breathing
Non- productive coughing
CBC result: Hematocrit, Hemoglobin, RBC below normal count.
Medications: Rocephin vial 1 gm
Omepron Capsule 20 mg
Zithromax tablet 500 mg

A care of a 31 year old adult male with a medical diagnosis of R/O pneumonia with a chief complaint of fever

Key Assessment:
Age
Vital Signs
Lifestyle
CBC laboratory result
AFB smear result
Nutrition: Diet…...

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