B. B. is a 22-year-old woman who was admitted and had surgery 3 days ago for a colectomy and colostomy due to inflammation and a perforated bowel. She has a history of Crohn’s disease. She has lost significant weight. Presently she is 5’2” and weighs 89 pounds. She has a surgical drain that is going to be removed today. Her vital signs are temperature 99.0 F orally, heart rate is 98 and regular, respirations are 22 and unlabored, and blood pressure is 118/72. She rates her pain a “4” on the numeric scale.
Then surgeon has just removed the surgical drain and you stay with the patient to complete your assessment. Her colostomy is intact and draining watery brownish color feces. Patient is alert and oriented to person, place, time and situation. She is able to follow the conversation, but you notice she is not making eye contact with you. You ask her what is wrong and she replies “How am I going to get a boyfriend with this on me? How am I going to have children? I look really sexy now.” She has tears in her eyes.
Concept map template
Nursing 110
Name: Adenike Aibor
Class: NSG 110
Due Date: 04/20/2021
Patient’s Initials: R.T.
Step 1: Complete the chart using the patient assigned to you. You may want to refer to the Physical Assessment Chapter in the Tres & Wilkinson text for assistance. Do not leave any box blank, use “Not Applicable” if there is absolutely nothing that you can identify for the box.
| Body Systems | Subjective Data | Objective Data |
| Neurologic | N/A | N/A |
| HEENT (Head, Eyes, Ears, Nose, Throat) | N/A | Closed head injury |
| Integument | N/A | Repaired fractures on right femur, tibia and radius. |
| Musculoskeletal | N/A | He can bend his elbow. He can propel self in the wheelchair. |
| Cardiovascular | N/A | Regular BP 110/72. HR regular at 68. |
| Respiratory | N/A | Respiration normal at 16. |
| GI | N/A | N/A |
| GU | N/A | N/A |
| Emotional/Social/Spiritual | Pain is “8” on the numeric scale. “I can’t believe they keep me here with a bunch of old people. What will my girlfriend and friends think?” | Percocet every four hours for pain. |
| Reproductive | N/A | N/A |
Step 2: Place the subjective and objective data under the appropriate Gordon’s Functional Pattern. Note: Findings may repeat in multiple boxes this is the process of forming “data clusters”. Not every box will have data – type not applicable under the data cluster, but give a definition. Expand and rearrange the boxes as needed.
Clustered Data (all relevant)
-Pain
Relevant Gordon Pattern: Health Perception/Health Management
Definition: : “Client’s perception of general health status and well-being. Adherence to preventive health practices.” (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
N/A
Relevant Gordon Pattern:
Sleep/Rest
Definition: Definition: “Patterns of sleep and relaxation periods during 24-hour day as well as quality and quantity”. (Doenges & Moorhouse, 2013,p.17)
Clustered Data (all relevant)
N/A
Relevant Gordon Pattern: Sexuality/Reproductive
Definition: “Client’s perceived satisfaction or dissatisfaction with sexuality. Reproductive stage and pattern”. (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
N/A
Relevant Gordon Pattern: Value/Belief
Definition: “Values, goals, or beliefs that guide choices or decisions.” (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
-Alert and oriented to person, place, day and time.
Relevant Gordon Pattern: Cognitive/Perception
Definition: “adequacy of sensory modes, such as vision, hearing, taste, touch, smell, pain perception, cognitive functional abilities.” (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
N/A
Relevant Gordon Pattern: Elimination
Definition: “Ability to excrete waste products.” (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
N/A
Relevant Gordon Pattern: Nutrition/Metabolic
Definition: Definition: “Patterns of food and fluid intake, fluid and electrolyte balance, general ability to heal”. (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
-Patient can move self in the wheelchair.
Relevant Gordon Pattern: Activity/Exercise
Definition: Definition: “Ability to engage in necessary/desired activities of life (work and leisure) and to obtain adequate sleep/rest”. (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
-He states his pain is “8” on the numeric scale.
-He can bend his elbow.
-He can move self in the wheelchair.
Relevant Gordon Pattern: Coping/Stress
Definition: “General coping patterns, stress tolerance, support systems, and perceived ability to control and manage situations”. (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
– “I can’t believe they put me here with a bunch of old people. What will my girlfriend and friends think?’
Relevant Gordon Pattern:
Self-Perception/Self-Concept
Definition: individual’s attitudes about self, perception of abilities, body image, identity, general sense of worth, and emotional patterns.” (Doenges & Moorhouse, 2013,p.17).
Clustered Data (all relevant)
-He has a girlfriend and friends.
Relevant Gordon Pattern:
Role/Relationship
Definition: “Client’s perception of
major roles and responsibilities in
current life situations”. (Doenges &
Moorhouse, 2013,p.17).
Patient Name: R.T.
Age: 32
Gender: Male
Chief Complaint: Pain related to head, femur, tibia and radius injuries.
Clustered Data (all relevant)
Patient has low Self perception
Relevant Gordon Pattern:
Name: Self perception/self-concept:
Dysfunctional
Associated Nursing diagnostic label:
Patient is worried about his girlfriend and friends seeing him in a nursing home, and amongst a group of old people
Patient Name: R.T.
Age: 32
Gender: Male
Situation: Patient is in pain after a bike
accident.
Priority Nursing Diagnostic Statement: Pain & anxiety.
Diagnostic Label: Acute Pain
Related to: Injury from recent bike crash
Evidence: – Patient has closed head injury, fractures on right femur, tibia and radius and wearing brace on fractured leg and fiberglass cast on fractured arm.
Goal: Assess pain level and bring it down to a level 2 in the next 2 hours.
2-3 SMART outcomes:
- Promote healing on fractures.
- Arrange therapy to help patient get back to walking on both legs.
- Advice patient to stay off foot to help healing.
In your own words, based on the data cues, what is the most important (priority) problem?
The most important priority is reducing the pain level and helping patient get back to using both legs in walking.
List and prioritize all Nursing Diagnostic Statements (3 part or 2 part) based on data clusters above (at least 3):
1.Low self –perception related to being on a wheel-chair and amongst old people.
2.Inability to cope with pain level due to injuries.
3.Anxiety related to fear of rejection by loved ones.
Step 3: Type in the Data Clusters. Identify the Gordon’s Pattern and functionality; Analyze the data cluster to determine the problem. Identify the appropriate Nursing Diagnostic Label (nursing diagnosis). Complete the remaining sections. Include arrows showing how each data cluster/problem influences others on the care map. . Add, Expand, or Rearrange the boxes as needed.
Clustered Data (all relevant)
The patient is in wheelchair.
Relevant Gordon Pattern
Name: Activity/Exercise
Dysfunctional
Associated Nursing diagnostic label:: Patient has
anxiety because he does not want his loved ones to see
that he is on a wheel-chair and cannot walk
Clustered Data (all relevant)
The patient states his that his pain is “8” on the numeric scale.
Relevant Gordon Pattern
Name: Coping/Stress
Dysfunctional
Associated Nursing diagnostic label: Acute pain related to head, and right femur, tibia and radius injuries
Reference
Doenges, M.E. & Moorhouse, M.F. (2013). Application of nursing process and nursing diagnosis: An interactive text for diagnostic reasoning. (6th ed.). F.A. Davis.
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