Concept Map -- Student Name & ID: _Yveline Fortilus Date: June 12, 2014 Week: 6 Page 1 of 2

Admitting Medical Diagnosis: Acute Diarrhea

Definition: A condition in which someone frequently passes
liquid feces (Collin, 2005).


Co-existing Diagnoses: (up to 3)
1. Congestive Heart Failure
2. Hypertension
3. Osteoarthritis

Priority Nursing Diagnosis: (NANDA)

Deficient fluid volume related to prolonged diarrhea secondary
infectious processes.



Key Data & Analysis (from
attached worksheet)
Cardiovascular S:
-Regular heart beat:76/mn
-generalized non pitting
edema
-pale skin and mucous
membrane
Respiratory S:
-Unlaboured breathing
- decreased air entry to the
base/ expiratory wheezes
Gastrointestinal S
-hyperactive bowel
sounds/slightly distended
abdomen/ passing flatus/ 10
loose BM on June 1/
Genitourinary S
Urine output <50ml/hr
Integumentary
Non elastic skin/ stage 2
pressure ulcer wound on
coccyx
2. Plan
Relevant Diagnostic Tests:
CBC
Electrolyte
Albumin level
Serum lactate level
c-difficile toxin
urinalysis
chest x ray
Relevant Psych/Social Analysis (Mental Health):
Pt is in the late adulthood
Pt is not oriented to time and place
Pt is calm and cooperative/irritable at time
Pt received phone calls from family(daughter and son)
all the time

3.Implementation Priority Goal (Health Outcome) related to nursing diagnosis.
(SMART)
The client will maintain fluid volume at a functional level in
three days.

IPC Team Client Care Priorities:
Control the Diarrhea
SW: Discharge planning
Chaplain: spiritual care
OT/PT: ROM /transfer practice







1. Assessment
(Priority) (Please
attach worksheet*)
Relevant Medications, Clinical Indications & Nursing Implications: (Appendix if
needed)
1. Asa 5- dalteparin
2. Metronidazole 6- clodipogrel sulphate
3. Vancomycin 7-potassium gluconate
4. Bisoprolol (Please see attach for clinical indications)
Nursing Interventions: (For priority nursing diagnosis) & citations:
1. Review the patients lab test result
Rationale: to evaluate the degree of fluid loss and determine
replacement need (Carpenito, 2013).

2. Administer scheduled medication as prescribed
Rationale: Medication s such as metronidazole and vancomycin
are used in the treatment of C-difficile infection (Doenges,
Moorhouse and Murr, 2013.
3. Observe patient for any elevation of temperature , cough,
crackles on the chest
Rationale: fluid correction may compromised the
cardiovascular system causing fluid overload (Doenges,
Moorhouse and Murr, 2013,

Teaching Plan:
Attach Appendix:
4. Evaluation of
health outcome
related to goal
Data & Analysis:
1- Goal met. By monitoring patient lab
result nurse realized that patient has
hypokalemia and has notified the
doctor.
2- Goal met. After one day of
administration of scheduled
medications patient has a reduction of
4 pasty BM a day.
3- Goal met. The patients vital signs
remain stable. Urine output increased
to 65ml/hr.

Relevant Medical Plan of Care: (Not
diagnostic tests)
1- Control the infection
2- Integration of patient back to
the retirement home
3- Supportive care measures

*GBC Health Assessment Data Collection Form: Part A & Part B
Concept Map Student: Yveline Fortilus__________________ Page 2


Additional Nursing Diagnoses: (in order of PRIORITY) Priority Goals:

1. Acute pain related to infectious disease process secondary to C-Difficile as
evidenced by client verbal report of pain in the abdomen
The client will verbalize a decrease in pain intensity in the next two hours.

2. Impaired skin integrity related to effects of pressure and constant maceration in
the coccyx area
The client will demonstrate progressive healing of the pressure ulcer in four days.

3. Risk for loneliness related to therapeutic isolation secondary to C- difficile
infection
The client will not show any signs of loneliness today.


Please note: See Marking Rubric for Concept Maps; 3/15 marks are allocated for discussion of your concept map with your faculty advisor (i.e. explaining rationale)



References: (APA 6
th
edition):


Carpenito, L. J.(2013). Nursing Diagnosis: Application to clinical practice (14th ed). Lippincott Williams & Wilkins

Collin, P. H. (2005). Dictionary of Medical Terms. London: A & C Black.

Doenges, M.,& Moorhouse,M., & Murr, A. C. (2013). Nursing Diagnosis Manual Planning, Individualizing, and Documenting Client care. Retrieved
September 19, 2013 from http://www.scribd.com/doc/33812048/76/readiness-for-enhanced-Self-Care







GBC: Concept Map Revised Spring 2014