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# Key Problem/ND # Key Problems/ND # Key Problem/ND

Risk for dec cardiac output Impaired gas exchange Risk for infection
Supporting data: Supporting data: Supporting data:
BP: 64/38 Diminished breath sounds WBC: 12.9
MAP: 46 Dyspnea Neutrophils: 12.38
Hemodynamic instability BiPAP requiring 50% FiO2 Cefepime IV 50mL/hr
Atrial fibrillation with RVR SPO2: 97% Vancomycin IV 200mL/hr
HR: 151 Tachypnea Diabetic
Cardiomegaly on CXR RR: 27

# Key Problem/ND:
# Key Problem/ND
Risk for fluid volume overload
Risk for electrolyte
Supporting data:
imbalance
AKI
Reason For Needing Health Care Supporting data:
Electrolyte imbalance
(Medical Dx/ Surgery) BUN: 77
BUN: 77
Septic shock, AKI, BP of 64/38 in emergency Creatinine: 2.55
Creatinine: 2.55
department Calcium: 7.9
Albumin: 1.8
Phosphate: 6.4
2+ pitting edema in lower
Focused assessment: Afib RVR
extremities
Cardiovascular, BP Muscle weakness
24 hour output 65mL

Allergies:
NKA

# Key Problem/ND # Key Problem/ND # Key Problem/ND

Anxiety Risk for shock Deficient knowledge
Supporting data: Supporting data: Supporting data:
Yelling out for help BP: 64/38 Confusion
Confusion MAP: 46 Ammonia: 56
Ammonia: 56 Hemodynamic instability Altered mental status
BiPAP on for entire shift Altered mental status Impaired verbal communication
Confusion
Poor oxygenation

Problem #1: Risk for dec cardiac output

General Goal: Maintain an adequate blood pressure with a MAP >65

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Predicted Behavioral Outcome Objective (s): The patient will have a MAP that consistently a over 65 on the
day of care.

Nursing Interventions Patient Responses

1. Assess blood pressure 1. BP 102/56

2. Assess heart rate and rhythm 2. HR 151, afib RVR
3. Check peripheral pulses 3. Radial +2, pedal +1; bilaterally
4. Monitor for neuro changes 4. Pt had new onset of confusion
5. Assess SpO2 5. 97% on BiPAP FiO2 50%
6. Monitor urine output 6. 65mL in 24 prior to shift start
Evaluation of outcome objectives: Patients blood pressure has improved since her arrival in the ED. Was 64/38
with a MAP of 46, now it is 102/56 with a MAP of 75

Problem #2: Impaired gas exchange

General Goal: Maintain adequate oxygenation
Predicted Behavioral Outcome Objective (s): The patient will maintain an SpO2 greater than 93% on the day
of care.

Nursing Interventions Patient Responses

1. Administer O2 as needed 1. SpO2 97% on BiPap FiO2 50%

2. Assess respiratory rate 2. Respiratory rate was 27/min
3. Assess respiratory effort 3. Breathing was labored
4. Auscultation respirations 4. Breath sounds were diminished
5. Monitor for neuro changes 5. New onset of confusion and restless
Evaluation of outcome objectives: Patient required BiPap with an FiO2 of 50% to maintain adequate
oxygenation of greater than 93% SpO2.

Problem #3: Risk for shock

General Goal: Display adequate perfusion

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Predicted Behavioral Outcome Objective (s): The patient will have palpable peripheral pulses and have an
adequate BP on the day of care.

Nursing Interventions Patient Responses

1. Administer phenylephrine 1. Vasoconstriction of vessels

2. Administer norepinephrine 2. Improvement of BP to stable level
3. Monitor BP closely via A-line 3. BP ranged from 94 SBP to 51 DBP
4. Monitor heart rate 4. HR ranged from 93-151, irregular,afib
5. Monitor bowel sounds 5. Active, no ileus
Evaluation of outcome objectives: Patients pulses were all palpable, extremities cool due to vasopressors.

Problem #4: Risk for fluid volume overload

General Goal: Patient will achieve fluid balance

Predicted Behavioral Outcome Objective (s): The patient will have a urine output greater than 30mL/hr on the
day of care.

Nursing Interventions Patient Responses

1. Monitor daily weights 1. Weighed gained 1kg since yesterday

2. Monitor I&O 2. 24hr intake:3926mL, output:65mL
3. Check CXR 3. Pulmonary vascular congestion
4. Assess for peripheral edema 4. +1 pitting on LLE & RLE
5. Auscultate lung sounds 5. Diminished with fine crackles
6. Assess for JVD 6. No JVD noted
7. Administer albumin 7. Removal of fluid in 3rd space
Evaluation of outcome objectives: Patients output is poor and pt is fluid overloaded as evidenced by 2nd and
3rd spacing.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Problem #5: Risk for infection

General Goal: Reduce complications from infection

Predicted Behavioral Outcome Objective (s): The patient will maintain immune response on the day of care.

Nursing Interventions Patient Responses

1. Monitor temperature 1. Temp 101.8 on arrival, 99.2 today

2. Monitor sputum color 2. Sputum tan/green
3. Monitor WBC count 3. WBC count 12.9
4. Administer antibiotics 4. Cefepime and vancomycin given
Evaluation of outcome objectives: Patients WBC count increased from previous shift indicating an immune
response to the infection.

Problem # 6: Risk for electrolyte imbalance

General Goal: Maintain electrolyte levels within the normal ranges

Predicted Behavioral Outcome Objective (s): The patient will tolerate electrolyte solutions on the day of care.

Nursing Interventions Patient Responses

1. Monitor electrolyte levels 1. CL, PO4, and Ca abnormal

2. Monitor renal function 2. Creatinine 2.55, BUN 77
3. Assess GFR 3. GFR 18
4. Administer isotonic solution 4. 0.9 NS given for electrolyte balance
Evaluation of outcome objectives: Patients electrolyte imbalance had improved slightly from previous day.

Problem #7: Anxiety

General Goal: Patient will tolerate treatments with minimal anxiety

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

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Predicted Behavioral Outcome Objective (s): The patient will reduce calls for help and be oriented to know
she’s being helped on the day of care.

Nursing Interventions Patient Responses

1. Assess heart rate 1. HR ranged from 93-151

2. Assess respiratory rate 2. RR ranged from 24-27
3. Monitor for confusion 3. Pt was very confused and not oriented
4. Administer lactulose for confusion 4. First dose given, no effect at this time
5. Maintain a calm environment 5. Pt was inconsolable
Evaluation of outcome objectives: Patient was not oriented and shouted out over us when we tried to console
her. Patient was most relaxed when she fell asleep.

Problem #8: Deficient knowledge

General Goal: Treat patients confusion so they can learn of their condition.

Predicted Behavioral Outcome Objective (s): The patient will respond to their lactulose and respond on the
day of care.

Nursing Interventions Patient Responses

1. Keep patients comfortable 1. Pt was repositioned, pillow support

2. Maintain a calm environment 2. BiPap seemed to overstimulate pt
3. Include patient in plan of care 3. Pt was explained everything we did
4. Treat confusion 4. Lactulose given
5. Monitor ammonia 5. Ammonia 56
6. Provide clear, simple explanations 6. Pt showed no understanding
Evaluation of outcome objectives: Patients high ammonia level needs treated and is a likely catalyst for her
new onset confusion. Treating this is a priority to get her in a better place mentally.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.