Concept Map

By: Debbie Cresta

Capella University

NURS-FPX6021: Biopsychosocial Concepts for Advanced Nursing Practice 1

Dr. Katie Hooven

June 2, 2021
 Concept Map

Patient Information

Name: Providencia Oquendo Gender: Female Age: 92

Vitals: Temp 36.4C (97.6F) B/P: 180/90 Pulse: 97 Resp. Rate: 25 02 Sat: 90%

Chief Complaint: Patient presented with pain radiating down mid chest, difficulty breathing, Swelling in lower extremities, and a low oxygen
saturation rate. She was hospitalized a week prior due to vomiting blood.

Medical History: Diabetes II, Hypertension, Prior stroke, Osteoarthritis, Anemia, and CHF
 Nursing Diagnosis
Fluid Volume overload due to decreased cardiac output as evidence by pitting edema in
lower extremities, enlarged heart, low saturation, and moderate to severe pulmonary
vascular congestion with bilateral pleural effusion.
Subjective Data: SOB, Pain radiating through mid-sternum, O2 sat low, and pitting
edema to both feet.
Objective Data: 02 sat at 90% with oxygen therapy, X-ray showed moderate to severe
pulmonary vascular congestion with bilateral pleural effusion difference note from
earlier x-ray taken in previous hospitalization.
Nursing Diagnosis Nursing Diagnosis
Activity intolerance related to imbalance between oxygen supply, the require needs for her limited
Risk for Decreased Cardiac Output
activities, and her weaknesses.
Subjective Data: complain of pain in middle of chest, SOB, Increased Heart rate and
Subjective Data: The patient said was continuously tired throughout the day, shortness of breath on
elevated blood pressure, prior recorded evidence of a stroke, being treated for atrial
exertion, changes in vital signs during activity, and because of her osteoarthritis has difficulty with
fibrillation.
her balance. Edema prevalent in both feet, was nauseous, increased her fluid intake based on soft
diet she was placed on during prior stay. Objective Data: Cardiologist confirmed need for surgery based on diagnostic tests. Taking
Eliquis due to A. Fib., and aspirin for previous mild stroke. BP and pulse elevated. Chest X-
Objective Data: X-ray and echogram showed a blockage in the artery leading to her heart, and fluid
ray confirmed pulmonary vascular congestion with bilateral pleural effusion.
build around her heart and lungs. 02 level at room air lower than normal, and BP elevated.

Nursing Interventions
Nursing Intervention
Independent intervention: Teach patient how monitor food and fluid intake. Keep it to
1500 calorie a day limit, monitor I & O, and monitor daily weight. Monitor vital signs Independent Intervention:
and check for pitting edema.

Rationale: Teaching patient how to monitor their food and fluid intake is vital in
preventing future flare ups. Monitoring their I&O is always a good indicator in helping
the medical team assess the needs of the patient.

Collaborative intervention: Give IV diuretics as prescribed. Maintain O2 Therapy as

prescribe by the doctor. Maintain a restricted caloric and fluid diet as prescribe by the
dietician.

Rational: Diuretics like Lasix are effective in removing excess fluid from the body
through the urine.

II: Sit the patient in the upright position.

Rationale: Elevation helps with breathing and removes pressure from chest area.

II: Encourage patient to do breathing exercise, as taught by respiratory Therapy.

Rationale: Performing breathing exercises taught by respiratory will help with

expansion of lung capacity.