TCC Nursing Program

NUR 2564 Advanced Medical Surgical

Key Problem Concept Map Key Problem

Risk for Infection
6 Fluid Volume Excess
Supporting Data
WBC count 15.33: Central line
placed: currently septic: surgery
yesterday to remove squamous cell
carcinoma on chest wall: Currently
Intubated: has indwelling Foley
catheter
Client Goal: Client will not acquire
any further infections; WBC count
will begin to normalize as patient
responds to antibiotic therapy
Key Problem 5 wall.
Risk for Aspiration
Supporting Data: Patient is
currently intubated with
endotracheal tube and is receiving
supplemental nutrition via
nasogastric tube
Client Goal: Swallow and digest
nasogastric feeding without
aspiration
Why was the client admitted?
Pt. Was life-flighted from
outlying hospital where he was
evaluated pH 7.2 & pCO2 of
60, CXR showing CHF,
cardiomegaly, volume
overload. Outlying hospital was
not equipped to care for the pt.
What is clients significant
history and/or co-morbidities?
HTN, CKD, bilat lung transplant 2004,
hx of rejection & chronic host vs graft
rejection. Hx of A-fib, CAD, stent
placed in 2003, single vessel disease,
squamous cell carcinoma on chest
Has the client had any
significant procedures/surgies
during this admission?
Pt. was intubated on arrival
Does the client have family? wife
has stayed at the bedside.
Other significant data: Patient
converted from NSR in the 70-80bpm
range to atrial fibrillation with RVR. Pt.
was started on an IV drip of Heparin
@ 30mL/hr. The pt. is
immunosuppressed, currently septic,
has fluid volume overload. My
interpretation of the ABGs indicating
partially compensated metabolic
acidosis.
3
Supporting Data: CXR indicating
cardiomegaly with evidence of fluid
volume overload, right mid lung
edema; Lung sounds diminished
bilaterally at the bases, edema
present and patient looks generally
puffy. BNP of 2547.5; Input
exceeded output with a negative
1583ml
Client Goal: Remain free of jugular
vein distention, positive
hepatojugular reflex, and gallop
heart rhythm
Key Problem 1
Decreased cardiac output
Supporting Data: Patient converted
from a normal sinus rhythm to atrial
fibrillation with RVR spontaneously
in the night.
Client Goal: Remain free of side
effects from the medications used to
achieve adequate cardiac output

Key Problem: 2 Key Problem 4

Impaired Gas Exchange
Supporting Data: Abnormal blood gasses; pCO2-
31mm/Hg; pH 7.28; pO2 125 mm Hg; CO2 21;
Lower extremities were blue-purple in color
indicating poor perfusion; CXR indicating fluid
volume overload and small bilateral pleural effusions.
Risk for Electrolyte Imbalance
Supporting Data: evidence of fluid volume overload
and the patient also has kidney disease; BUN 54;
Creatinine 2.80; CA 7.9; Na 134; K 4.5; Phos 4.2; mag
2.4; Input exceeded output with a negative 1583mls

Client Goal: Demonstrate improved ventilation and Client Goal: Patient will attain normal serum
adequate oxygenation as evidenced by blood gas potassium, sodium, calcium, and phosphorus
levels within normal parameters for that client