Mind Map #3

Mind Map #3

1. Admitting Diagnosis

   • Chest Pain
     • dyspnea w/ exertion
   • Previous Medical History
     • List of Problems
       • New Problems
         • Atrialfibrillation, Chronic
         • Nausea, Vomitting
         • migraines
         • Dyspnea w/ exertion
       • Historic Problems
         • Anxiety
         • Essential Hypertension
           • Former Smoker
         • Chest Pain
         • Obesity, Unspecified
     • Previous Surgeries
       • Hysterectomy
       • Cholecystectomy
       • SVT with Ablation
     • Medications
       • See List
   • Labs and Diagnostic Values
     • Labs
       • MCHC 31.9 (Low)
       • Nearly all Labs (Including Triponin) were within normal range
       • MCH 26.7 (Low)
     • Blood Panel
       • WBC 11.7 x 10^3 (High)
   • Treatments
     • transesophageal echocardiogram
     • ECG Procedure
     • On Holter Monitor
       • Daily Weights
     • Nutritional Plan
       • Educational Plan for Obesity
       • Regular Diet
     • Meds
   • Nursing Diagnosis
     • Dx #1: Overweight related to high frequency of restaurant or fried food as evidenced by adult BMI of 25.
     • Dx #2: Decreased cardiac output related to afterload as evidenced by dyspnea
   • Head to Toe Assessment
     • EENT
       • 3mm Pupils
       • Cardinal Gazes ✔
       • Whisper Test ✔
       • Oral Mucosa moist and pink
       • Cavities Filled
       • PERRLA
     • Neurological Assessment
       • Oriented x3
       • Pt Denies pain at this time
       • Grip Strength ✔
     • Respiratory
       • Clear; all lobes
     • Cardiac
       • Heart Rate Regular
       • Capillary Refill: < 3 sec
       • Pedal Pulse: +2
       • Carotid, Radial, Tibialis, Pulse +3
     • Skin
       • IV Left Forearm
       • Turgor ✔
       • small incision in peritoneal area
     • Abdomen
       • soft
       • Normoactive sounds

2. Patient Demographics

   • Initals: CM, Female
   • Status: Full Code
   • BMI: 308
   • Allergies: Sulfa Drugs; PCN
   • Religion: Baptist
   • Race: White
     • Ethnicity: Not hispanic or Latino
       • Language: English