NURS 205 CONCEPT MAP

Erikson’s Developmental Stage of Life Cycle: Older

Adulthood__________________________________________

Task: integrity versus despair

Health-Illness Continuum: (Circle One) Maximum Health Health

Illness Death

Oxygen Needs/Circulation Safety/Skin/Wounds/ Neurological/Neurovascula

no pain in chest Drains/Infections/Sensory r
adequate breathing, no Rt inner thigh decub and sacral Peripheral neuropathy
accessory muscle use, decub Ataxia
normal, unlabored @ 16 UTI Transverse myelitis
Fall risk

Nursing Problems
Prioritize according to Maslow’s Hierarchy
Nursing Diagnoses (5)
Nutrition/Hydration Comfort
High protein diet 1. Impaired tissue integrity r/t immobility Position for comfort
Soft/chopped, thin liquids c/o feet getting cold
anorexia 2. Urine retention r/t inability to void while sleeping, ensure
adequate warmth
3. Self care deficit, feeding, dressing, reposition Q 2hrs
grooming r/t ataxia, transverse myelitis,
peripheral neuropathy

4. Risk for injury r/t peripheral neuropathy,

Elimination ataxia, transverse myelitis, immobility
Straight cath Q 4-6 hrs Rest/Activity
Constipation 5. Knowledge deficit r/t disease process and Lower extremities
Hard mass over bladder medications immobile
Encourage upper limb
movements, exercise
Reposition Q 2 hrs

Love/Belonging/Culture Anxiety/Concerns/Fear
Knowledge Needs

/Sexuality Medication knowledge

Coping/Body Image/ needed
Sexuality Further coping with
Uses prayer and family to progression of illness
cope coping skills
Accepting of immobility Discharge planning
Accepts care with some involvement
concern