Frankley John is a 38 years old female who has just received news from her PCP that she has lung mass she was admitted to the hospital for further check up, her mother died with lung cancer, patient was distraught and crying.

Please use this patient information below to write Analysis paper. (This information is just for student to use for homework, please use this clinical patient information and please follow instruction to complete this homework Analysis paper.)

Frankley John is a 38 years old female who has just received news from her PCP that she has lung mass she was admitted to the hospital for further check up, her mother died with lung cancer, patient was distraught and crying. She has no family in the area except her wife, they are self employed they have no insurance.

She is a small obese woman of 4′ 11 and weighs 225 lbs. She smokes 2 packs of cigarettes-stating, “I don’t want to quit however, she is complaining of difficulty breathing with shortness of breath when ambulating .
lung mass biopsy revealed that she has a cancerous tumor lower lobe. The plan is to remove the mass and radiation therapy.
BP is 120/65, P72, R16 with a persistent cough but is unable to bring up her secretions. So, at times she feels like she is choking. Temperature 99.8. When the nurse assist Ms. John to the bathroom she starts to experience shortness of breath. Respiration 12. In addition, she has difficulty ambulating due to her weight, and almost falls. The nurse immediately sits her in the chair and administer 2 liters of nasal 02. Ms. John feels a little better and states, “It’s hard for me to get around I use a cane to get around when I am alone”. Alberta states “She knows she has to lose weight also but she loves to eat”. “Besides I have lung cancer and my mother died, life is short”.
When the nurse sits with Alberta she states, “My mother died when I was young, what am I going to do” She starts to get angry and tells the nurse to leave the room.

The nurse returns 30 minutes later to check on Ms. John. The nurse observes John and her wife Galilea eating an entire pizza pie, with a 2liter bottle of coke.

The care map is a diagramed version of the nursing process and it is “used to organize patient data, analyze relationships in the data, establish priorities, build on previous knowledge, identify what you do not understand, and enable you to take a holistic view of the patient’s situation (Schuster, 2002).”

Mapping out thought process helps the instructor understand how the student is thinking about nursing process and planning care. Care maps can stand on their own. Nursing students must be able to discuss what they have done. Therefore, each part of the Individual Care Map assignment requires an analysis paper and a care map. The best part about this is that both build upon the previous part.

This is what you do:

Individual Care map 1

Read the above case study.

Organize the data from the case study by completing this table:

Body system	Subjective data	Objective data
Neuro
HEENT
Integument
Musculoskeletal
Cariovascular
Respiratory
GI
GU
Emotional/ Social /Spiritual
Reproductive

Which of the data are related to each other? Cluster those data together here (data clusters) and on the care map by placing the data clusters in text boxes around the patient image. Connect the data to the patient.

Example:. States pain level “8/10”, “I can’t move right now.”, grimacing, pointing to RLQ, incision in RLQ of abdomen, HR 98, Bp 138/90, guarding abdomen (these data cues are clustered together because they demonstrate that the patient is in pain)

1.

2.

3.

4.

add more as needed

See the next page for a picture

Include pertinent background, medical orders, and medications off to the side, if available. They are important but we are trying to determine the client’s response to the situation. (Important to remember!!)

Review the worksheet of Gordon’s Patterns. Which of Gordon’s Patterns are represented by the data clusters? How do you know this? READ THE DEFINITIONS and Label the connecting lines of data clusters from the patient with the Gordon’s patterns:

What is the purpose of labeling these connecting lines? It helps a nurse to determine if more assessment data is needed to make a decision and it helps us to use Gordon’s patterns to select associated nursing diagnoses to label the response of the patient to the situation.

Now, Which of the Gordon’s Patterns are dysfunctional? Label those. That means it’s a problem!

Next, (1) Which of the data clusters influences other data clusters? Connect those with a dashed line. I used a different color as well.

(2) How does the pertinent medical history (PMH) relate to the client’s situation? Is there a relationship?Connect those with a different color and dashed line.

(3) Medications ordered? How does the medications ordered affect the data clusters? Connect those. (I used red and a smaller dash for all parts medical because those are dependent diagnoses.):

(keep going to the next page)

Process for writing a Nursing Diagnosis:

Now the fun part! Determining relevant associated Nursing Diagnoses (also called the diagnostic label, problem, or diagnosis). Go to Appendix H of the Dongess book. We talked about this in class. There are so many nursing diagnoses that it may seem overwhelming. For each data cluster, try to determine by looking at the defining characteristics of the data clusters (defining characteristics = data cues) which Nursing diagnosis is associated. For example, let’s use the information above:

States pain level “8/10”, “I can’t move right now.”, grimacing, pointing to RLQ, incision in RLQ of abdomen, HR 98, Bp 138/90, guarding abdomen

·        I read that the client is in pain, so I’m going to the “p’s” to see if pain is there, and it is! I have to decide now, is it chronic or acute pain. READ THE DEFINITION. By the definition, the client is in acute pain.

·        Next, do the defining characteristics match up? They do. So, this looks like a good choice for this data cluster.

·        Finally, what is the cause of the problem? This is also called the etiology, related to, or risk factors.And, Dongess has a list of related to factors waiting for you to consider. The most important part of this consideration of the cause of the problem is that you do not select a medical diagnosis; because the nurse cannot “cure” the patient of the medical diagnosis (that’s the physician’s job). We relieve the response to the situation and promote health.

Once I complete diagnostic labeling (the nursing diagnosis) and determine the cause of the problem (related to) and support that there is a problem by including the evidence, I have to put it together in a diagnostic statement:

i.e. Associated NDx: This is just an example please use the patient information paper provided

Acute pain RT disrupted tissue integrity secondary to surgery evidenced by States pain level “8/10”, “I can’t move right now.”, grimacing, pointing to RLQ, incision in RLQ of abdomen, HR 98, Bp 138/90, guarding abdomen

Repeat the process for each data cluster and create a list of nursing diagnoses that are associated with the Gordon’s patterns selected based upon the data clusters. Here is how I indicate this on the care map:

Prioritize the Nursing Diagnoses:

We did this in class. There are several methods and some may be more applicable to your client’s situation. Start by setting up your table:

	Problem-oriented	Risk/ potential	Health Promotion
Physiological
Psychosocial
Educational

(hint: ABC’, the table above, Maslow’s, etc)

Write one patient-centered goal to show resolution of the problem.

Care map done!

WHAT?!? Really? Yes. So, you get write about what you just did and how you thought about it. Each Gordon’s Patterns set shall be a paragraph. Tell me about all the thinking you did to develop the associated nursing diagnoses for that data cluster set. Then, move on to the next data cluster and make that a new paragraph. Don’t assume I know anything about your thought process, because I don’t. Show me how you are thinking! How to begin…………….

I have a list of questions for you to answer. This is the paper! Include ALL of the questions with the Answers of the questions:

1.    In separate paragraphs, explain the data clusters and which Gordon’s pattern is represented by each data cluster. Which Gordon’s patterns are Functional or Dysfunctional? (Take each of the data clusters and discuss how they helped you.)

2.    Using Gordon’s as a guide, which nursing diagnoses are identified for this client? (Separate each Gordon’s pattern into a paragraph and discuss your process).

3.    List ALL of the identified associated nursing diagnoses in the:                                              “Problem”Related to “_____ “ Evidenced by “____” format.

4.    Show in a diagram how the nursing diagnoses listed were prioritized. The diagram should be inserted into the correct answer space.

5.    Which nursing diagnosis is most important to address with this client? Explain how this was determined. What was the method of prioritization?

6.    Which nursing diagnosis is second most important to address with this client? Explain how this was determined. What was the method of prioritization?

7.    Which nursing diagnosis is least important to address with this client? Explain how this was determined. What was the method of prioritization?

Complete the Nursing process by answering the questions below and including the information in the explanation paper:

1.    What is the goal for the client to show that the priority problem is reduced or resolved? Remember what a goal is…

2.    What would a nurse (you) need to do for the client to help the client meet the goal? These are interventions.

3.    How would you know that the client has met the goal? What would the evaluation be?

4.    Incorporate this into the Care Map:

The analysis paper must be in word.doc or .docx format.

2 sentences may be quoted or paraphrased with appropriate citation in each paragraph or section. Reference for each source must be listed on the reference page in APA format and citation in-text for unoriginal work