Scenario
David is a 19-year-old college student who dove into a swimming pool where he sustained dislocation and fractures of the C2-C3 vertebrae. David was pulled unresponsive from the water and was not breathing. CPR was initiated. Paramedics were able to resuscitate David and he was transported to a multi-level trauma center where he is placed on a ventilator and he begins his recovery. Based on his injuries, develop a concept map.
Center Box
The center box should include the primary medical diagnosis or reason for admission, a focused assessment, and goals for the patient.
Primary Medical Diagnosis or Reason for Admission
Briefly list the medical diagnosis at the top of the center box.
Focused Assessments
Next, list those areas of patient assessment that should be focused on based upon the primary medical/surgical diagnosis.
As applicable, include the currently treated diagnosis, for the patient.
Organize the focused assessment by concepts. For example, with a diagnosis of pneumonia, focused assessment should include the following concepts:
Oxygenation (Resp assess – crackles, wheezing, dyspnea, tachypnea, O2 sats
Cough: (productive, purulent, persistent, hemoptysis)
Comfort (pleuritic CP, weakness)
Infection (fever – chills – WBC count – confusion)
Note: The focused assessment must be specific; thus, writing “vital signs, respiratory system, lab data” would be incorrect.
