Nursing 101 Care Map

Supporting assessment data
(Signs & Symptoms)
 
·        
BMI
greater than 35
·        
Patients
comments of sedentary lifestyle
·        
Deficient
knowledge about nutritional needs, food intake and/or appropriate food prep.

Patient (initials, age, admitting diagnosis)
 
·        
E.E.
·        
61yr
old male
·        
Dx:
Pneumonia, hypoxia

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Supporting assessment data
(Signs & Symptoms)
 
·        
Patient’s
verbalization of sedentary lifestyle
·        
Patient
is obese (409 pounds), with contributing diagnoses of obesity, hypoxia, and
pneumonia limiting physical activities.
 

Pathophysiology of problem
 
·        
Obesity
is an excess accumulation of body fat; BMI greater than 27.8 for men.
·        
Most
commonly obesity is caused by overeating and insufficient exercise.
 

Related Concepts
·        
Diabetes
Type 2
·        
Obesity
·        
Depression
·        
Sleep
Apnea
·        
Hypoxia

·        
Hypothyroidism

 

Pathophysiology of
problem
 
·        
compromised effective
oxygen transport and physical conditioning surpass the patient’s physical and
psychological abilities

Nursing Diagnosis Statement
 
Imbalanced Nutrition: more than body requires related to Diagnosis of
obesity AEB BMI greater than 35 and sedentary lifestyle.
 

Related Medications
·        
insulin
lispro(Humalog)
·        
insulin
glargine(Lantus)
·        
atorvastatin(Lipitor)
·        
duloxetine(Cymbalta)
·        
levothyroxine(Synthroid)
 

Nursing Diagnosis Statement
 
Risk for activity Intolerance related to generalized weakness and debilitation
AEB acute/chronic illnesses, obesity and sedentary lifestyle

Short term Goal/Outcome
·        
Patient
will choose appropriate meals (4carbs/meal) for weight reduction by discharge
date.
·        
Patent
will verbalize 4 benefits of weight loss by discharge.
·        
Patient
will state 3 factors contributing to weight gain by discharge
 

Related Labs/Diagnostics
·        
Blood
glucose levels AC and HS
·        
Lipid
panel
·        
Liver
enzymes
·        
Thyroid
function test
·        
HGBA1C
·        
CBC
·        
BMP

Short term Goal/Outcome
·        
Patient
will perfom ROM exercises in bed three times a day until discharge
·        
Perform
deep-breathing exercises three or more times daily.
·        
Patient
to sit up in a chair for at least 30 minutes three times daily.
·        
Patient
to walk down the hall 150 feet or more six times a day until discharge.

Interventions (at least 4)
·        
Monitor
weight, waist circumference and calculate BMI
·        
Assess
the effects or complication of being overweight (DM2, activity tolerance)
·        
Implement/review
food diary
·        
Teach
patient about proper food choices and food modifications to assist with
weight loss
 

Consults or Interventions Needed
 
·        
Consult
with dietitian
·        
Consult
with Endocrinology
·        
Consult
Physical Therapy
·        
Consult
Respiratory
·        
Consult
Cardiology

Interventions (at least 4)
·        
Monitor
VS before and after activity, wait 3 minutes after activity to assess
·        
Monitor
patients sleep patterns
·        
Assess
patients need for assistive devices to achieve goals (walker, cane, portable
oxygen, ect)
·        
Assist
patient with prioritizing tasks, so non-essential tasks are completed last,
if able to tolerate. 

Evaluation of Short-term Goal/Outcome
 
Met     Partially Met     Unmet 

 
Supportive criteria:

Patient/Family Teaching Needs
·        
Teach
the patient how to spread meals out throughout the day and to eat meals at
regular times and amounts to control weight and blood sugar levels.
·        
Teach
the patient about importance of exercise and activity to control weight and
blood sugar levels.
·        
Discuss
with the patient the importance of support from family and friends for
required lifestyle changes.
·        
Help
the patient formulate weekly goals to help achieve long term goals.

Evaluation of Short-term Goal/Outcome
 
Met     Partially Met     Unmet 

 
Supportive criteria: