The document uploaded below that is labeled: My Concept Map is the paper that needs to be completed with concept mapping, problems, interventions,
rationales and citations from Nursing Diagnosis Handbook. I already filled in the key information
Nursing Care Plan Guideline for collecting and presenting data
Patient Initials (only): L.R. Approximate age: 4 weeks
Date of Admission: 1/20/2022 Code Status____________
1. Overview of client, including reason for admission/current problem (present summary in a narrative format):
Male newborn, admission DOB 1/20/2022, born at 35 weeks, weight 3.22 kg due to prematurity, Head circumference 38 cm, 98% room air oxygen, abnormal
fetal development, NKDA, MCA(Middle Cerebral Artery Stroke), hydrocephalus, R multicystic dysplastic kidney, L hydronephrosis, urine backup in the kidney.
Long term Ureterostomy.
2. Primary Medical Diagnosis (give a brief definition & explanation of the pathophysiology):
Multicysitc dysplastic kidney
Rhombencephalosynapsis
Respiratory distress/RDS
Hydrocephalus
Hydronephrosis
Prematurity of infant: 35 weeks
Renal failure
3. Functional Health Patterns:
A. Health Perception/Health Management:
Lion is eating through an NG tube and oral feedings if interested. He has a ureterostomy, 15 ml output. He can produce stools.
B. Nutrition-Metabolic:
Total Calorie 24, Route NG and oral, 200 ml/kg/day
C. Elimination: Urine output 15 ml, no stool today
D. Activity/Exercise:
E. Sleep/Rest:
F. Cognitive/Perceptual: Middle Cerebral Artery (stroke) Sudden onset of neurological deficit.
G. Self Perception/Self Concept:
H. Role/Relationship: Mother and father were visiting and brother at home.
I. Sexuality/Reproduction: Male