CONCEPT MAP WORKSHEET
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Mona Hernandez had influenza 10 days prior to admittance. Symptoms: Dry couch, fever, malaise.
Saw PCM yesterday and was diagnosed via chest x-ray (white spots in RLL) with pneumonia, admitted at this
time. Pneumonia is an infection of the lungs. It is caused by bacteria, virus, or fungi. Sputum sent to lab to
determine cause. Infection inflames alveoli which then fill with pus/fluid which reduces O₂ in blood.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
Mona Hernandez
Chest X-Ray – ID pneumonia in 72 y/o RLL pneumonia
lungs (white spots) Female Rales/crackles w/ auscultation
NKA Productive cough
Sputum culture – determine Hispanic Colored mucus
organism causing pneumonia to Catholic Malaise
isolate correct treatment plan. Tachycardia
Specimen collected prior to broad Fever
spectrum ABX administration. ↑ respiratory rate
Low SPO₂
Low BP
ANTICIPATED NURSING INTERVENTIONS
Raised Pt to High sitting position
Ambulate x3 daily
Asses O₂
Administer supplemental 0₂ via nasal cannula (3 L/min)
Auscultate lungs
Evaluate pts pain level (1/10 scale)
Educate pt on
- pneumonia
- incentive spirometer
- importance of coughing, emesis, ambulation
Encouraged coughing
Vitals every 4 hrs
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION vSim – Amy, RN
Your name, position (RN), unit you are
working on
SITUATION Mona Hernandez
72 y/o F
Patient’s name, age, specific reason for visit Pneumonia
BACKGROUND Pneumonia Reg diet, encourage fluid intake
Admitted yesterday Vitals every 4 hrs
Patient’s primary diagnosis, date of CBC w/ differential Ambulate x3 daily to chair
admission, current orders for patient ABG and BMP Maintain 94% O₂ sat min
Hydrochlorothiazide 25 mg PO x1 daily
Ceftriaxone 400 mg IVPB x1 daily
Heparin 5000 units SQ x2 daily
Acetaminophen 650 mg PRN 6hrs for pain
Guaifenesin Elixir 100 mg PO PRN 4hrs for cough
ASSESSMENT Pt has pneumonia
Orientated x3, appears tired
Current pertinent assessment data using head Sharp pain – chest - w/cough 6/10 before 650mg APAP 1/10 after
to toe approach, pertinent diagnostics, vital Shortness of breath w/ activity
signs
Temp 101
Breaths 18 p/min
SPO₂ 94% - on supplemental room O₂
BP 134/80 mmHg
RECOMMENDATION Nope
Any orders or recommendations you mayhave
for this patient
DESCRIBE DISEASE PROCESS AFFECTING PATIENT
(INCLUDE PATHOPHYSIOLOGY OF DISEASE PROCESS)
Mona Hernandez had influenza 10 days prior to admittance. Symptoms: Dry couch, fever, malaise.
Saw PCM yesterday and was diagnosed via chest x-ray (white spots in RLL) with pneumonia, admitted at this
time. Pneumonia is an infection of the lungs. It is caused by bacteria, virus, or fungi. Sputum sent to lab to
determine cause. Infection inflames alveoli which then fill with pus/fluid which reduces O₂ in blood.
DIAGNOSTIC TESTS PATIENT INFORMATION ANTICIPATED PHYSICAL FINDINGS
(REASON FOR TEST AND RESULTS)
Mona Hernandez
Chest X-Ray – ID pneumonia in 72 y/o RLL pneumonia
lungs (white spots) Female Rales/crackles w/ auscultation
NKA Productive cough
Sputum culture – determine Hispanic Colored mucus
organism causing pneumonia to Catholic Malaise
isolate correct treatment plan. Tachycardia
Specimen collected prior to broad Fever
spectrum ABX administration. ↑ respiratory rate
Low SPO₂
Low BP
ANTICIPATED NURSING INTERVENTIONS
Raised Pt to High sitting position
Ambulate x3 daily
Asses O₂
Administer supplemental 0₂ via nasal cannula (3 L/min)
Auscultate lungs
Evaluate pts pain level (1/10 scale)
Educate pt on
- pneumonia
- incentive spirometer
- importance of coughing, emesis, ambulation
Encouraged coughing
Vitals every 4 hrs
, vSim ISBAR ACTIVITY STUDENT WORKSHEET
INTRODUCTION vSim – Amy, RN
Your name, position (RN), unit you are
working on
SITUATION Mona Hernandez
72 y/o F
Patient’s name, age, specific reason for visit Pneumonia
BACKGROUND Pneumonia Reg diet, encourage fluid intake
Admitted yesterday Vitals every 4 hrs
Patient’s primary diagnosis, date of CBC w/ differential Ambulate x3 daily to chair
admission, current orders for patient ABG and BMP Maintain 94% O₂ sat min
Hydrochlorothiazide 25 mg PO x1 daily
Ceftriaxone 400 mg IVPB x1 daily
Heparin 5000 units SQ x2 daily
Acetaminophen 650 mg PRN 6hrs for pain
Guaifenesin Elixir 100 mg PO PRN 4hrs for cough
ASSESSMENT Pt has pneumonia
Orientated x3, appears tired
Current pertinent assessment data using head Sharp pain – chest - w/cough 6/10 before 650mg APAP 1/10 after
to toe approach, pertinent diagnostics, vital Shortness of breath w/ activity
signs
Temp 101
Breaths 18 p/min
SPO₂ 94% - on supplemental room O₂
BP 134/80 mmHg
RECOMMENDATION Nope
Any orders or recommendations you mayhave
for this patient
