Concept Map: Caitlyn Howe 1

#1 Key Problem #4 Key Problems #5 Key Problem

Impaired Gas Exchange Fluid Volume Excess Risk for Bleeding

Supporting Data Supporting Data Supporting Data

Ventilator Dependence +1 edema in BLE Heparin therapy
Hx of Smoking Chest CT: Moderate bilateral aPTT 68.2
Blood Gas Resp Alkalosis: ph 7.5, pleural effusions Femoral line
CO2 24.2, HCO3 18.4 Bumetanide use
Rhonchouros lung sounds
Chest X-ray: Increasing R lung
opacities

#6 Key Problem Key Problem

Anxiety Reason For Needing Health Care #3 AKI
Cardiopulmonary Arrest
Supporting Data Supporting Data
Intubated Key Assessments BUN 67
Need for sedatives (Fentanyl, Respiratory Status Creatinine 3.7
Dexmedetomidine) Assess cardiac lab values (BNP, Trop) GFR 12
Breathing over vent Assess electrolyte lab values
Assess blood gases
Organ Perfusion (Creatinine, Urine Output)
Neuro Checks
Fluid Status
EKG/ Constant cardiac monitoring

#2 Key Problem
Impaired Cardiac Output

Supporting Data
Hx CAD, stent placement x3
Hypotensive- 95/57, 94/50
+1 edema BLE
BNP >70,000
Troponin 275

Problem # ____1___: Impaired Gas Exchange

General Goal:

Predicted Behavioral Outcome Objective (s): The patient will maintain clear lung fields and remain free of
signs of respiratory distress
P. Schuster, Concept Mapping: A Critical Thinking on Approach, Davis, 2002.
the day of care.
 Concept Map: Caitlyn Howe 2

Nursing Interventions Patient Responses

Nursing Interventions Patient Responses

1) Monitor O2 continuously 1) Pt maintained >92%

2) Auscultate lung sounds 2) Pt had no adventitious sounds
3) Monitor skin for signs of cyanosis 3) Pt had no signs of cyanosis
4) Monitor for LOC changes 4) Pt had no LOC changes
5) Draw and assess ABG levels 5) Pt ABG: pH 7.50, CO2 24.2,
6) Elevate HOB HCO3 17.6
7) Monitor respiratory rate, depth, and 6) Pt tolerated well
effort 7) Pt had stable RR, low effort,
8) Suction ETT as needed normal depth
8) Pt tolerated well

Evaluation of outcome objectives: Pt had no adventitious sounds for entire shift. No respiratory distress
occurred for entire shift

Problem # ___2____: Impaired Cardiac Output

General Goal:

Nursing
Predicted Behavioral Outcome Objective (s): The patient will Interventions
demonstrate Patientoutput
adequate cardiac Responses
as
evidenced by stable pulse, blood pressure, MAP, and strong pulses
on the day of care.
Nursing Interventions Patient Responses

1) Assess heart rate and rhythm 1) HR 75, Normal sinus rhythm

2) Monitor BP and MAP 2) BP 110/55, MAP 73
3) Assess peripheral pulses 3) +2 peripheral pulses BLE and BUE
4) Assess capillary refill 4) Cap refill <3 sec
5) Auscultate heart sounds 5) S1, S2
6) Note skin color, temp, edema, and 6) Skin color pink, warm, generalized
moisture trace edema, dry
7) Assess O2 saturation 7) SPO2 93%
8) Assess BNP and Troponin 8) BNP >70,000, Troponin 275

Evaluation of outcome objectives: Pt demonstrated adequate cardiac output for entire shift. Strong peripheral
pulses, normal sinus rhythm, stable HR, MAP >60 for entire shift.

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

Problem # ___3____: AKI 3
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will display appropriate urinary output, and stable
weight and vital signs
on the day of care.

Nursing Interventions Patient Responses

1) Assess for edema 1) Generalized trace edema
2) Strict I&O monitoring 2) Cumulative fluid balance +2,613 ml
3) Daily Weights 3) No change in weight from previous
4) Administer Bumex day
5)Monitor BP and HR 4) Hourly output of 60mls, IV drip
6)Monitor electrolyte levels 5) BP and HR stable
7)Monitor BUN and creatinine 6) Na 143, K 4.6, Cl 108, Mg 1.5
8)Monitor GFR 7) BUN 67, Creatinine 3.7
8)GFR 12

Evaluation of outcome objectives: Pt maintained and output of at least 60mls an hour for entire shift. Trace
edema present. Weight unchanged from previous day, vitals remained stable.

Problem # ___4____: Fluid Volume Excess

General Goal:

Predicted Behavioral Outcome Objective (s): The patient will maintain urine output of greater than 30ml/hr

on the day of care.

Nursing Interventions Patient Responses

1) Assess hourly output 1) 60mls

2) Daily weights 2) no change in weight from previous
3) Assess for neck vein distension day
4) Auscultate lung and heart sounds 3) no neck vein distension
5) Assess for edema 4) no adventitious sounds
6) Administer Bumex 5) generalized trace edema
7) Assess urine output in response to 6) IV drip, pt vitals stable
diuretic therapy 7) 60mls every hour for entire shift
8) Assess neuro status 8) no change in neuro status for entire
shift

Evaluation of outcome objectives: Pt maintained an output of 60mls/hr for entire shift while on Bumex drip.
No weight gain, vitals stable. Neuro status unchanged.

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

 4
Problem # ___5____: Risk for Bleeding
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will experience bleeding as evidenced by stable BP,
hct, hgb, and coagulation profiles
on the day of care.
Nursing Interventions Patient Responses

1) Monitor Hgb and Hct panel levels 1) Hgb 7.1, Hct 21.5
2) Monitor aPTT levels 2) aPTT 68.2
3) Assess IV sites 3) IV sites clean, dry, patent
4) Monitor vital signs 4) Vitals stable
5) Assess skin for petechia or any new 5) No petechia or ecchymosis
ecchymosis, 6) No blood in urine or stool
6) Monitor for blood in urine or stool 7)Platelets 193
7) Monitor platelets 8) No blood from suctioning in ETT
8) Monitor ETT secretions for blood

Evaluation of outcome objectives: Pt experienced no bleeding for entire shift. Hgb and Hct slightly low but
stable. Coag profiles in therapeutic range.

Problem # ___6____: Anxiety

General Goal:

Predicted Behavioral Outcome Objective (s): The patient will remain calm and report low levels of anxiety

on the day of care.

Nursing Interventions Patient Responses

1) Manage pain 1) Pt CPOT 0
2) Administer sedation as ordered 2) Pt on fentanyl drip
3) Reposition q2h 3) Pt tolerated well
4) Assess RASS score 4) RASS -1
5) Explain all actions and procedures 5) Pt sedated
6) Familiarize patient with 6) Pt sedated
environment 7) HR and BP stable
7) Assess HR and BP 8) Pt not breathing over vent
8) Assess compliance with ventilator

Evaluation of outcome objectives: Pt was comfortably sedated for entire shift, no signs of agitation or pain.
HR and BP remained stable.

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