PGCC Nursing Concept Map Diagnosis Essay

Instructions for Completion of the Concept Map Paper

Use a holistic approach to develop a scenario based on your assigned resident’s admitting, current, and ongoing health issues.

Use the Concept Map format 

Include “four” individualized prioritized NANDA(s)

Remember, your assigned resident has actual problems as opposed to potential and risk for

No less than four prioritized interventions for each NANDA

• 1 Short term and 1 Long term goal
• APA formatted paper required
• Title Page 

Resident’s Scenario

Concept Map pages (one NANDA with interventions, goals, and evaluations that correlate with this NANDA per page. “Do not forget the legend”)

Conclusions (what are your recommendations – no more than 3 paragraphs)

• References (within 5 years unless considered and labeled a historical reference

Library offers an APA 7th edition Workshop************   

                          Diagnosis = cancer of the breast, pain, Ambulated with Cain 

Comorbidities:

• Pathological subtrochanteric fracture of right femur
•                                                     History of Present Illness
• 41F w/ hx of Stage IV Breast Cancer with metastases 

after mechanical fall downstairs w/ resultant displaced

• comminuted fracture right proximal femoral shaft s/p ORIF.She tolerated the procedure well and postop course largely
• uncomplicated. Pt is WBAT bilateral LE. CT scan did not show any lytic or sclerotic
• lesion in this location although the patient did have increased uptake in both femurs on

bone scan from thus, this was classified as a pathologic fracture. Per Oncology 

further Chemotherapy on hold until patient completes Acute Rehab. PT is currently

• taking Letrozole and last dose of Pertuzumab and Trastuzumab was 3/9/2022.
• At the time of admission evaluation. Report continence of bladder bowel. Denies cognitive issues and has no difficulty swallowing.

Patient lives by herself and works as an Attorney from home. She has stairs and is bel

her prior level of independent functioning. Premorbid independent with all ADLs,

iADLs, and mobility.

                                                 History and Physical Reports

41F w/ hx of Stage IV Breast Cancer with metastases after mechanical fall downstairs w/ resultant displaced,

comminuted fracture right proximal femoral shaft.

REHAB

– Comprehensive PM&R/PT/OT/Nursing/Psych to improve functional status, strength

endurance, mobility, and ADs with the goal of safe discharge.

– Impairments: decreased strength, decreased endurance, decreased balance

– Disabilities: decreased ability to perform ADs/lADLs, decreased ambulation

– Precautions: Fall precautions, WBAT bilateral LE

– Pain: Tylenol PRN +

– Sleep: Melatonin PRÑ

                     Neuro/MSK

right femur fracture, pathologic

– displaced, comminuted fracture right proximal femoral shaft.

– supplement vitamin D

                         Respiratory

At risk for atelectasis

– incentive spirometry

                             GI

At risk for constipation

– bowel program as needed to prevent and treat constipation

                      GU

At risk for urinary retention

– routine PVR to r/o urinary retention

                           Stage IV Breast Cancer with metastases

– pathologic fx R femur

– takes Letrozole

– last dose of Pertuzumab and Trastuzumab was 3/9/2022.

– further Chemotherapy on hold until patient completes Acute Rehab.

             FEN:

– Diet: regular diet

– Monitor and replete electrolytes as needed

Prophy

– Gl: protoxin, takes omeprazole at home

– DVT: _ Lovenox daily