Cedar Crest College

Physiological Stressor # 1 Physiological Stressor # 2 S

S:(Doenges,
“I’m having trouble breathing”, Student Concept Map, p1
2016, p (Doenges, 2016,I can’t
p S: “My lower back hurts” T
move without needing to stop for a Life threatening stressors
U
D
minute to catch my breath” penetrate Core O: Redness, pain 3 out of 10, non- E
Abnormal Symptoms penetrate blanchable, shallow/open ulcer, pink N
O: Shortness of breath, malignancy of T
normal line of defense wound bed, Braden scale: 4
lung, abnormal breathing, exercise
Stressors penetrate flexible line of N
intolerance. A: Decreased tissure perfusion r/t A
defense & ^risk for penetration of NLD
M
immobility aeb redness, pain, non-
A: Ineffective breathing pattern r/t E
blanchable shallow/open sore.
dyspnea aeb abnormal breathing D
P: Improve tissue perfusion and resist A
P: Improve breathing pattern by end of Medical Diagnosis: T
infection of open wound. E
visit Pulmonary emboli
Julianna
CC: Shortness of Brauchle
Breath

Positive Variable
Positive Variable Aiding Resistance:
Aiding Defense: Dev. Stage:
Immunization. Patient
Lives at home with son, Ego Integrity received flu shot.
has an ample amount vs. Despair
of familial support.
HPI:

Patient is part of a melanoma

clinical trial where a clot in lungs
in CT scan was found 11/18/2016
Other Stressor # 4
Physiological Stressor # 3
S: “I’m scared”, “I’m anxious to go
S: “I feel dizzy”, “I need three people to home”, “The doctors make me nervous”
help me” “I can’t really get off the toilet”
Flexible line of defense O: Major life changes, prescription
O: Unable to rise without assistance, fall antidepressants, distressed look on
score of 6, anemia (RBC 2.29), shortness of Normal line of defense patient’s face
breath
Lines of Resistance A: Anxiety r/t threat to current status
A: Risk for falls related to anemia aeb major life changes
P: Reduce/ Eliminate falls on day of care. Basic Structure/Central P: Reduce amount of anxiety patient
Core
feels towards doctors and current
status.
 Cedar Crest College - Nursing Concept Map (page 1)
Attach Clinical prep sheet to this form
Student Name: Julianna Brauchle
Nursing Dx # : Ineffective breathing pattern related to dyspnea as evidenced by abnormal breathing
Behavioral Outcome: The client will…. Improve breathing pattern on the day of care.

Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/
goals)
Evaluate client’s respiratory
status: Note rate and depth of
inspirations counting for one full
minute if rate is irregular.
Scientific Rationale for Selected Implementation Phase
Interventions (Indicate what you, the nurse,
the therapist, etc did on the day
of care)
Rate may be faster or slower than Respiratory rate assessed at
usual 0800 and 1100 during vital
(Doenges, 2016) signs check.
Evaluation Phase/Client Response to
care (Note specific and measurable data
you collected after the intervention to
give evidence if your planned
interventions helped the client)
RR at 0800 assessed as 18
RR at 1100 assessed at 18
Regular rate and rhythm found.

For underlying pulmonary Oxygen was not administered Client’s pulsoox improved with simple
conditions and current breathing techniques such as deep
Administer oxygen at lowest respiratory problem breathing.
concentration needed. (Doenges, 2016)

To prevent slumping and Client’s head of bed was Client states that she was able to breath
promote rest- promote maximal elevated. better, client looked more relaxed and
inspiration pink.
Elevate the head of the bed or (Doenges, 2016)
have client sit up in chair;
support with pillows; or position
of comfort.

To limit fatigue and improve Client was given rest times Client stated appreciation for rest
endurance. throughout ambulation. periods, was stronger when more help
(Doenges, 2016) period were given and able to help with
Review energy conservation movement.
techniques (Pacing activities,
taking short rest periods)
Reposition client frequently To enhance respiratory effort and
ventilation of all lung segments,
especially if immobility is a
factor.
(Doenges, 2016)
Client position was changed Client was able to move herself into
frequently. different positions and often liked to
raise or lower head of the bed to make
breathing easier.

Outcomes met? Why or Why not? Explain: Outcomes were met, with simple teaching of position change the client could breathe more easily.

Cedar Crest College - Nursing Concept Map (page 2)

Attach Clinical prep sheet to this form
Student Name: Julianna Brauchle
Nursing Dx # : Impaired skin integrity related to mechanical factors as evidenced by alteration in skin integrity
Behavioral Outcome: The client will…. Have improved tissue perfusion and decreased risk for infection on the day of care.

Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/
goals)
Note character and color of
drainage, when present.
Scientific Rationale for Selected
Interventions
(Doenges, 2016
Which can cause or exacerbate
skin irritation or excoriation
(Doenges, 2016)
Implementation Phase
(Indicate what you, the nurse,
the therapist, etc did on the day
of care)
Wound was evaluated, no
discharge found.
Evaluation Phase/Client Response to
care (Note specific and measurable data
you collected after the intervention to
give evidence if your planned
interventions helped the client)
No discharge was found in wound area.

Clarify interventions, needs, and Client’s pain level was assessed Client stated pain was at a 3 out of ten,
Determine client’s level of priorities using a ten point scale however client expressed she did not
discomfort. (Doenges, 2016) want any pain medications.

Keep areas dry and clean,
carefully dress wounds, support
wound.
To assist body’s natural process Client’s would was cleaned Z-guard was applied to patient’s sacral
of repair during bed bath. wound. Patient’s wound was kept dry
(Doenges, 2016) and clean.
 To assist with developing plan of Order was placed for wound Patient stated she wanted the ulcer taken
Consult with physician or wound care for problematic or care referral. care of and that she was open to letting
specialist as needed. potentially serious wounds the wound care specialist look at her
(Doenges, 2016) sacrum.

Use appropriate barrier
dressing/wound coverings,
drainage appliances, and skin-
protective agents for
open/draining wounds.
To protect wounds and
surrounding tissues from
excoriating secretions or drainage
and promote wound healing
(Doenges, 2016)
Z-guard was applied to patient’s Patient’s sacral area was kept clean and
sacral area. the nurse said it looked as though it was
not getting any worse.

Outcomes met? Why or Why not? Explain Outcomes were met, nurse stated wound was not getting worse.

Cedar Crest College - Nursing Concept Map (page 3)

Attach Clinical prep sheet to this form
Student Name: Julianna Brauchle
Nursing Dx # : Risk for falls related to anemia
Behavioral Outcome: The client will…. Not experience falls on the day of care.

Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/
goals)
Evaluate client’s current
disorders/ conditions that could
enhance risk for potential falls
Scientific Rationale for Selected
Interventions
Acute situation can affect client
care (Doenges, 2016, p 303)
Implementation Phase
(Indicate what you, the nurse,
the therapist, etc did on the day
of care)
Observed client’s chart.
Evaluation Phase/Client Response to
care (Note specific and measurable data
you collected after the intervention to
give evidence if your planned
interventions helped the client)
Client’s red blood cell count was 2.29
indicating anemia which can cause fall
risk.

Collaborate in treatment of To improve client’s overall health Order was placed by nurse for Patient received blood transfusion over
disease or condition (Doenges, 2016, p 304) blood transfusion. the course of day of care, patient’s RBC
and blood counts increased. Patient
 stated she felt batter.

Recommend/implement needed To manage conditions that could Provided patient with non-slip Patient looked more steady and stated
interventions and safety devices contribute to falling (Doenges, socks and walker. she felt more stable.
2016, p 304)

Provide or encourage use of Balance and movement may be Encouraged use of analgesics. Patient refused analgesics.
analgesics before activity if pain impaired by pain (Doenges, 2016,
in interfering. p 304)

Educated client/caregivers in fall
precaution
Fall prevention is necessary, but
need to protect client must be
balanced with preserving
independence (Doenges, 2016, p
304).
Client was educated in Client verbally expressed understanding
ambulation. of teaching of waiting to stand so as to
not get dizzy, taking rest periods.

Outcomes met? Why or Why not? Explain Outcomes were met, patient did not have any falls on day of care.

Cedar Crest College - Nursing Concept Map (page 4)

Attach Clinical prep sheet to this form
Student Name: Julianna Brauchle
Nursing Dx # : Anxiety related to threat to current status aeb major life changes
Behavioral Outcome: The client will…. Experience reduced anxiety on the day of care.

Nursing Interventions:
Independent, Dependent &
Collaborative (all need to directly
relate to meeting outcomes/
goals)
Be available to client for listening
and talking
Scientific Rationale for Selected
Interventions
Establish rapport helps client
outlook on illness. (Doenges,
2016)
Implementation Phase
(Indicate what you, the nurse,
the therapist, etc did on the day
of care)
Talked with client for 20
minutes about stressors
Evaluation Phase/Client Response to
care (Note specific and measurable data
you collected after the intervention to
give evidence if your planned
interventions helped the client)
Client stated she felt better after talking
with student nurse
Establish therapeutic
relationship, conveying empathy.
Clarify meaning of feelings or
actions by providing feedback and
checking meaning with client.
Accept client as is.
Allow behavior to belong to the
client; do not respond personally.
Outcomes met? Why or Why not? Explain
Enables client to become
comfortable and to being looking
at feelings and dealing with
situation (Doenges, 2016)
Validates reality of feelings
(Doenges, 2016).
Client may need to be where they
are at moment (Doenges, 2016).
Reacting personally can escalate
the situation (Doenges, 2016).
Outcomes were met, patient stated she felt better than she had the day before.
Asked patient to tell me about
her experiences with doctors.
Asked patient to clarify
meaning of anxiety
Accepted client for who she
was, explained she was alright
to be feeling the way she was.
Student nurse did not attempt
to change the way the client was
behaving in times she was
adamant.
Patient looked more relaxed.
Patient stated she was anxious because
she felts doctors were just using her as a
bill.
Patient expressed that she felt nobody
accepted her.
The client was able to resolve her own
issues quickly without the student nurse
escalating the situation.
References:

Moorhouse, M. F., & Doenges, M. E. (2016). Nurse's clinical pocket manual: Nursing diagnoses, care planning, and documentation. Philadelphia:
Davis.