1

Support problems with clinical patient data, including abnormal physical assessment
findings, treatments, medications, and IV’s, abnormal diagnostic and lab tests, medical Droplet
history, emotional state and pain. Also, identify key assessments that are related to the precaution for
reason for health care (chief medical diagnosis/surgical procedure) and put these in the influenza A.
Patient has
central box. If you do not know what box to put data in, then put it off to the side of the
severe PVD
map.

#2 Key Problem/ND #3 Key Problems/ND #1 Key Problem/ND

Ineffective peripheral tissue Impaired tissue integrity r/t fluid Ineffective airway clearance
perfusion r/t disease process AEB excess, pressure, nutritional r/t secretions AEB rhonchi
altered skin characteristics, deficit, altered circulation AEB
edema, absent pulses damaged tissue

#5 Key Problem/ND:
#6 Key Problem/ND
Anxiety r/t impaired verbal
Impaired verbal
communication, ineffective
Patient was found down at home for an communication r/t presence of
airway clearance AEB fidgeting,
unknown amount of time. May have been a mechanical airway (Trach)
glancing about, and restlessness
cocaine overdose. Patient’s status declined AEB cannot speak
once brought to the hospital and he needed to
be intubated. Patient was unable to wean off
the vent and had surgery to place a trach and
peg on 2/19/2018.

#4 Key Problem/ND #8 Key Problem/ND #7 Key Problem/ND

Acute pain r/t surgical procedure
AEB Patient nodding yes when
asked if pain present, increased
blood pressure, respiratory rate,
and heart rate.
Risk for aspiration r/t presence Risk for infection r/t surgery
of tracheostomy and surgery to and pooling of secretions
place trach

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Problem # ___2____: Ineffective peripheral tissue perfusion r/t disease process AEB altered skin
characteristics, edema, absent pulses
General Goal: Pt will demonstrate adequate tissue perfusion AEB palpable peripheral pulses.
Predicted Behavioral Outcome Objective (s): The patient will have Post Tibial and Pedal
Pulses measured by a Doppler for my entire shift.
Nursing Interventions:
1. Check peripheral pulses.
2. Asses temp and color of skin
3. Check Capillary Refill
4. Asses edema
5. Asses for pain in the extremities
6. Asses for presence of ulcers
7. Elevate edematous legs and ensure no pressure under the knee and heels to prevent
pressure ulcers

Patient Responses:
1. Radial +1 and equal bilaterally, Right Post Tib with Doppler, Left Pedal with Doppler,
Absent Right Pedal
2. Color usual for ethnicity. Skin cool to touch, especially BLE
3. Greater than 3 seconds BUE/BLE
4. +1 pitting edema BUE, +2 pitting edema BLE
5. Pt would grimace and withdrawal because of pain in BLE.
6. Pt had several ulcers on BLE
7. Pt tolerated well and no new evidence of skin breakdown present

Evaluation of outcome objectives: Outcome partially met. Bilateral radial +1, Absent pedal
pulse in right foot, Doppler pulse right post tib, Doppler pulse with left pedal.

Problem # ____3___: Impaired tissue integrity r/t fluid excess, pressure, nutritional deficit,
altered circulation AEB damaged tissue
General Goal: Pt will experience a wound that decreases in size and has granulation tissue
Predicted Behavioral Outcome Objective (s): The patient wounds will have no further
breakdown and the dressing on the coccyx will stay dry and intact during my shift
Nursing Interventions:
1. Asses the site of impaired tissue integrity

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2. Monitor for color changes, redness, swelling, warmth

3. Evaluate the use of support surfaces
4. Assess the clients nutritional status
5. Maintain the HOB at the lowest possible to reduce shear and friction
Patient Response:
1. Several ulcers on BLE. All are open to air and hydrophor applied to BLE. Two quarter
sized wounds on each buttock and one quarter sized wound on coccyx. The wounds on
the coccyx/buttocks are from pressure, miconazole nitrate 2% cream is applied and they
are covered with an ABD pad.
2. Ulcers are red and there is 2+ pitting edema to both legs. The legs are cold to touch.
3. Patient has a specialty air mattress and pillows are used to turn patient every two hours
4. Patient on a tube feeding: 1.5 calorie with fiber and 50ml/hr. Patients also on a
continuous drip of D5 with 0.45% NaCl with KCl 20 at 40ml/hr for fluid upkeep and
electrolyte stability.

Evaluation of outcome objectives: The wounds showed no further breakdown during my shift. I
also cared for the patient one week later and there was further breakdown on BLE but not further
breakdown for the wounds on the coccyx/buttocks. The dressing on the coccyx/buttocks was
clean/dry/intact on both days of care.

Problem # ___1____: Ineffective airway clearance r/t secretions AEB rhonchi

General Goal: Patient will maintain a patent airway at all times
Predicted Behavioral Outcome Objective (s): The patient will tolerate pressure support mode
AEB respiratory rate WDL and SPO2 > 90%
Nursing Interventions:
1. Auscultate breath sounds q1-q4 hours
2. Monitor respiratory patterns, including rate, depth, and effort
3. Monitor blood gas values and pulse oxygen saturation levels
4. Administer oxygen as ordered
5. Suction the patient correctly and PRN
Patient Response:
1. The first day of care patient had clear/diminished breath sounds. The second time I
provided care, patient had rhonchi.
2. Patient had a regular respiratory rate (12 the first time of care. 10 the second time of
care.) Patient had a normal depth on both times of care. Patient seemed to have a difficult
time breathing.
3. First day of care: pH- 7.483, PCO2- 40.1, PO2- 133.5, HCO3- 29.4, Uncompensated
metabolic alkalosis, SPO2- was not reading the first day of care. Several places were
tried, even the forehead and we could not get a reading. Second day of care: pH- 7.478,
PCO2- 42.3, PO2- 58.5, HCO3- 30.7, Uncompensated metabolic alkalosis, SPO2- 99%.

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4. The first day of care: FiO2- 35. The second day of care: FiO2- 35.
5. Patient tolerated suctioning
Evaluation of outcome objectives: Outcome partially met. The first day of care the patient was
unable to be on pressure support mode. The second day of care, the patient tolerated pressure
support mode well.

Problem # ___5____: Anxiety r/t impaired verbal communication, ineffective airway clearance
AEB fidgeting, glancing about, and restlessness
General Goal: Have a decrease in the amount of anxiety r/t health status
Predicted Behavioral Outcome Objective (s): The patient will have vital signs that reflect
baseline and have facial expressions/ activity levels that reflect decreased distress during my shift
on the second day of care.
Nursing Interventions:
1. Rule out withdrawal form alcohol as the cause of anxiety
2. Explain all activities and procedures that involve the client
3. Provide medication to help client decrease level of anxiety
4. Assess the clients level of anxiety and physical reactions to anxiety
5. Monitor vital signs for any increases
Patient Response:
1. Patient is known to have issues with alcohol, but it is clear that withdrawal is not
occurring. There are no symptoms of alcohol withdrawal occurring. Patient can nod head
appropriately to yes or no questions and states he feels anxious.
2. Patient understood all activities performed such as creams that needed to be applied,
turning, and medications that were given.
3. Patient receives Seroquel 25mg at 9am
4. Patient can nod head appropriately and when asked if feeling anxious the patient nods
yes. Patient reaches for trach when unrestrained. Patient seemed restless in the morning
but seemed to relax throughout the shift.
5. BP was 138/123 and then 159/83. RR was 22 and then 10. There was a decrease in vitals
after morning medication was given and patient had someone in the room with him.
Evaluation of outcome objectives: Outcome partially met. Vital signs were increased but after
measures were taken, they returned to baseline for the patient. Patient also showed signs of
decreased distress after measures were taken as well.

Problem # ___6____: Impaired verbal communication r/t presence of mechanical airway

(Trach) AEB cannot speak
General Goal: Pt will use alternate methods of communication effectively
Predicted Behavioral Outcome Objective (s): The patient will demonstrate understanding even
if unable to speak by nodding yes or no during my shift.
Nursing Interventions:
1. Assess the language spoken by the patient
2. Make the call light readily available
3. Explain all health care procedures
4. Use picture boards when appropriate

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5. Assess ability to read and write as a n alternate form of communication

Patient Response:
1. Patients primary language is English
2. The call light is with the patient and able to pressed at all times because the patient is able
to respond to yes/no questions and use a picture board
3. All health care procedures explained and patient nodded yes for understanding
4. Patient is accurately able to use a picture board when asked
5. Patient is able to read the picture board. Ability to write was not assessed.
Evaluation of outcome objectives: Outcome met. Patient is able to nod appropriately to any yes
or no question during the entire shift.

Problem # ____4___: Acute pain r/t surgical procedure AEB Patient nodding yes when asked if
pain present, increased blood pressure, respiratory rate, and heart rate.
General Goal: Patients level of pain will decrease to 0/10 or a manageable level
Predicted Behavioral Outcome Objective (s): Patient will notify me for a pain intensity level
that is consistently greater than the comfort-function ability and medication will help decrease
pain level during my shift
Nursing Interventions:
1. Assess pain level
2. Assume that pain is present if the client is unable to self-report and there is tissue injury
3. Provide analgesia as ordered, when appropriate, and when available
4. Perform nursing care when the patient is comfortable
5. Assess respiratory status after pain medication administration
6. Monitor vital signs for an increase that can be from pain
Patient Response:
1. Patient nods that he is in pain when asked. He seems restless and when asked if he is
uncomfortable he nods yes.
2. The first day of care, patient was not awake and responding to questions. He has several
wounds/ulcers and pulls away when legs are touched. Responded to pain.
3. Patient received Dilaudid for pain q2 hours on the second day of care
4. 30 minutes after administration of pain medication I would perform my assessment and
put cream on the patient’s wounds/ulcers when ordered.
5. His respiratory rate decreased from 22 to 10 after administration of pain medication
6. Blood pressure reduced from 138/123 to 159/83.
Evaluation of outcome objectives: Outcome met. Patient would notify me when in pain and
patient was satisfied with response to pain medication.

Problem # ___8____: Risk for aspiration r/t presence of tracheostomy and surgery to place trach
General Goal: Patient will not aspirate
Predicted Behavioral Outcome Objective (s): The patient will maintain a patent airway and
clear lung sounds during my shift
Nursing Interventions:
1. Monitor respiratory rate, depth, and effort

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2. Auscultate lung sounds frequently

3. Take vital signs frequently, noting an onset of temperature
4. Keep the head of bed elevated at 30-45 degrees
5. Provide meticulous oral care
Patient Response:
1. Patient’s respiratory rate was 12 on the first day of care. On the second day of care the
respiratory rate was 22 but decreased to 10 with pain and anxiety intervention.
2. Patients lung sounds were clear/diminished on the first day of care. On the second day of
care patient had rhonchi.
3. Vital signs are taken every hour and the temperature ranged from 97-98 degrees
4. HOB was at 30 degrees both days and the patient tolerated well.
5. Oral care is provided at least once a shift and PRN
Evaluation of outcome objectives: Outcome partially met. Patient maintained a patent airway
but lung sounds were diminished on the first day of care and rhonchi was present on the second
day of care.

Problem # ____7___: Risk for infection r/t surgery and pooling of secretions
General Goal: Patient will remain free from signs and symptoms of infection
Predicted Behavioral Outcome Objective (s): Patient will maintain a WBC count within
normal limits from the day before and the day of care provided
Nursing Interventions:
1. Observe and report signs of infection
2. Note and report WBC lab values
3. Use appropriate hand hygiene
4. Follow standard precautions and wear gloves during any contact with body fluid
5. Follow transmission based precautions
6. Ensure good oral care
7. Use strategies to prevent HCAP
8. Assess skin for color, moisture, texture, and turgor
Patient Response:
1. Patient has wounds that are red and there is swelling on the coccyx, buttocks, and legs.
2. WBC values: 2/14/18 7.8, 2/15/18 9.0, 2/21/18 16.1, 2/22/18 12.5
3. Hand washing or alcohol based hand rub was used upon entrance and exit of the room
4. Gloves were worn every time any contact with body fluid was possible
5. Patient was in droplet precautions for influenza A so a mask was worn
6. Oral care was provided once a shift and PRN
7. Patient is on the VAP bundle
8. Skin is usual for ethnicity. Skin is dry. Turgor is poor
Evaluation of outcome objectives: Outcome partially met. The first day of care, the WBC count
was in normal range. The second day of care the count was elevated. This can be from surgery or
underlying infection.

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