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Data don’t
know where
to put in
boxes:

Concept Map Key Problem/ND:

Key Problem/ND: Decreased Cardiac Output
Key Problems/ND: Supporting Data:
#1 Ineffective Gas Exchange #2 Impaired Spontaneous #4
Cardiac Arrest x3
Supporting Data: Ventilation BP= 111/43 MAP= 62
ABGs on Admission (9/11/18): Supporting Data: 5mg midodrine- Vasopressor
7.348(ph), 34.4(PC02), On Ventilator to increase BP.
102.9(P02), 18.5(HC03) Trach- “8” cuffed shiley EKG- T wave abnormal;
= Partially compensated Mode- AC/VC prolonged QT.
metabolic acidosis. Rate- 12 (RR=20) 150mg mexiletine-
ABGs on day of care (9/28/18): FI02- 70 TV- 500 antiarrhythmic.
7.374(ph), 51.3(PC02), PEEP- 8 SP02 range- 88-97% Troponin= 0.03- Cardiac
70.2(P02), 29.3(HC03) Sedation: Sublimaze (Fentanyl) Arrest.
=Compensated respiratory 5ml/hr- R. basilic (pink-PICC Hyperlipidemia hx.
acidosis. double lumen.) 16mg norepinephrine
SP02 range= 88-97% (w/ .70 40mg Protonix & 15ml Peridex 1.9ml/hr- R. basilic (white
FI02) b.i.d.= VAP prophylaxis. PICC double lumen) to
Hx: Pt. first came into ED w/ 1mg IV Ativan PRN for anxiety. increase BP.
SOB. Suction Q4 & as needed.
#5 Key Problem/ND:
Key Problem/ND: Lev
Excess Fluid Volume
#3
Ineffective Airway Clearance Supporting Data:
Supporting Data: Reason For Needing Health Care: Edema in upper/lower
Pneumonia Cardiac Arrest x3 extremities.
Rhonchi upper lobes (R/L) ARDS Upper- trace. Lower- 1+ non
Diminished lower lobes (R/L) 75 yo. Female pitting.
Thick tan/ pink tint sputum when Full Code Daily Weights:
suctioned. Key Assessments: Day of care- 216
WBC= 23 (H) VS Day prior- 206
Neutrophils=15.26 (H) Cardiac & Respiratory Assessments 24 intake= 4,231ml
Monocytes= 1.35 (H) I&0 24 output= 2,524ml
Eosinophils= 0.84 (H) Allergies: Cumulative fluid balance=
1.5g Vancomycin 150ml/hr Codeine (rash) 1,707ml
Turn Q2; elevate HOB 30 degrees CHF
Hemodilution
Cl=93 (L) RBC=2.63 (L)
#7 Key Problem/ND: Hgb= 7.7 (L) Hct= 24.5 (L)
Impaired Social Interaction #6 Key Problem/ND: Nacl 9% 60ml/hr R. basilic
Supporting Data: Imbalanced Nutrition (white PICC double lumen)
Depression Supporting Data: Lasix(furosemide) 20mg- loop
1mg Ativan IV PRN for NPO diuretic for fluid overload
anxiety/depression. PEG Tube- Tube Feed Standard w/ K= 4.4
Tracheostomy Fiber 55ml/hr
Nods head when spoke to-no Protein/Calorie Malnutrition
verbal communication. Albumin=2.8 (L)
Total Protein =5.7 (L)

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

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Problem # 1: Ineffective Gas Exchange

General Goal: Adequate Gas Exchange

Predicted Behavioral Outcome Objective (s):

Pt. SP02 will remain above 90% and morning ABGs will be in normal ranges on day of care

Nursing Interventions Patient Responses

1. Keep updated on ABGs 1. Ph- 7.374, PCO2- 51.3, P02-70.2,

2. Assess lung sounds HCO3-29.3
3. Assess vital signs 2. Upper R/L-Rhonchi Lower R/L-
4. Elevate HOB 30 degrees/Turn q2 Diminished
5. Assess chest x ray results 3. Temp- 98.3, BP-111/43, Map-62, HR-
6. Assess for agitation/restlessness 82
7. Hyper-oxygenate before suctioning 4. SP02- 88-97%, RR=20
8. Monitor Ventilator 5. Bilateral patchy spaces; R. pleural
effusion
6. Frequent tremors in extremities
7. SP02 94-97% when suctioned
8. Ac/vc rate-12 Fi02-70 TV-500 PEEP-8

Evaluation of outcome objectives:

Goal not met. SP02 range was 88%-97% throughout my shift. Morning ABG values indicated compensated
respiratory acidosis.

Problem # 2: Impaired Spontaneous Ventilation

General Goal: Maintain Adequate Ventilation

Predicted Behavioral Outcome Objective (s):

Pt. will not exhibit physical signs of respiratory distress or physical signs of worsening infection on day of
care.

Nursing Interventions Patient Responses

1. Assess SP02 1. 88%-97%

2. Assess vent settings
3. Suction q2/PRN
4. Administer 40mg Protonix
5. Peridex 15ml mouth care
6. Fentanyl sedation effectiveness
7. Assess Chest x-ray results
8. Administer 1.5g Vancomycin IVPB
for pneumonia.
2. AC/VC: Rate- 12, Fi02- 70, TV-500, PEEP-8
3. Thick tan/pink tint secretions
4. No aspiration
5. Removed thick tan secretions from mouth
6. Pt. calm in bed; CPOT= 2
7. Pneumonia; pleural effusion
8. No sign of nephrotoxicity (output >30ml/hr)

Evaluation of outcome objectives:

Goal not met. SP02 range was 88%-97% throughout my shift and newest chest x-ray indicated pneumonia.
Secretions are thick tan with a pink tint. There is still a need for Vancomycin antibiotic.

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

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Problem # 3: Ineffective Airway Clearance

General Goal: Effective Airway Clearance

Predicted Behavioral Outcome Objective (s):

Pt will have clear bilateral breath sounds and clear, thin secretions when suctioning on day of care.

Nursing Interventions Patient Responses

1. Auscultate lung sounds 1.Upper R/L=rhonchi Lower R/L=diminished

2. Suction q2/PRN
3.Assess Chest x-ray
4.Assess labs indicative of infection
5.Elevate HOB 30 degrees/turn q2
6.Administer 1.5g Vancomycin 150ml/hr
7. Monitor for use of accessory muscles
8.Monitor agitation/restlessness
2. thick tan/pink tint secretions
3.Pneumonia/ pleural effusion
4. WBC:2.3, neutrophil:15.26, monocytes:1.35,
eosinophils: 0.84
5. SP02 88-97%
6. No sign of nephrotoxicity (output >30ml/hr)
7. no retractions
8.Frequent tremors of extremities

Evaluation of outcome objectives:

Goal not met. Rhonchi heard bilaterally in upper lobes, diminished lower lobes and thick tan/pink tiny
secretions when suctioned.

Problem # 4: Decreased Cardiac Output

General Goal: Increased Cardiac Output

Predicted Behavioral Outcome Objective (s):

Pt. will remain in NSR, no angina and vital signs within normal limits on my shift.

Nursing Interventions Patient Responses

1. Assess heart sounds 1. S1,S2

2. Monitor EKG 2. On admin.= abnorm. Twave/Prolonged QT.
Today=NSR
3. Assess HR 3. 82
4. 6hr urine output 4. 825ml
5. Monitor Troponin 5. 0.03
6. Administer 150mg mexiletine (antiarrhythmic) 6. NSR
7. Administer norepinephrine (vasopressor) 7. BP= 111/43
8. Assess capillary refill 8. Less than 3 seconds

Evaluation of outcome objectives:

Goal not met. Blood pressure remained low (111/43), even after vasopressor administration. EKG indicated
NSR. When I asked my patient if she had any chest pain, she shook her head “no”.

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

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Problem # 5: Excess Fluid Volume

General Goal: Balanced Fluid Volume

Predicted Behavioral Outcome Objective (s):

Pt. will have a urine output of at least 30ml/hr.

Nursing Interventions Patient Responses

1. Assess edema 1.Upper= trace; Lower= +1 non pitting

2. Assess urine output 2.825ml over 6 hr
3. Assess RBC lab 3. 2.63 (L)
4. Daily weight 4. 216 pounds (10 pound gain in one day)
5. Administer 20mg Lasix over 1-2 mins 5. 825ml urine output; K=4.4
6.Assess fluid balance 6.4,231-2524=1,707 (24hr)
7. Assess Hgb & Hct lab 7. hgb=7.7 (L); hct= 24.5 (L)
8. Asses Cl lab 8. 93 (L)

Evaluation of outcome objectives:

Goal met. With administration of a loop diuretic, Lasix 20mg, pt. urine output was 625ml in my 6 hour shift.
RBC, hgb & hct levels indicate hemodilution.

Problem # 6: Imbalanced Nutrition

General Goal: Balanced Nutrition

Predicted Behavioral Outcome Objective (s):

Pt. will benefit from tube feeding at 55ml/hr evidenced by adequate Protein and Albumin levels.

Nursing Interventions Patient Responses

1. Asses bowel sounds 1. active

2. Asses residual at 8am 2. 10ml of gastric contents
3. Assess PEG tube 3. Clean, in place, infusing
4. Assess Feeding 4. Fiber 55ml/hr; pt denies discomfort
5. Check Albumin level 5. 2.8 (L)
6. Check total protein level 6. 5.7 (L)
7. Assess abdomen 7. Soft; non distended
8. Bowel movements 8. None on shift even after 150mg Colace

Evaluation of outcome objectives:

Goal not met. Low total protein and albumin levels indicate malnutrition.

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

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Problem # 7: Impaired Social Interaction

General Goal: Effective Social Interaction

Predicted Behavioral Outcome Objective (s):

Pt. will nod/shake head to yes/no questions and follow commands.

Nursing Interventions Patient Responses

1. Use CPOT for pain 1. 2

2. Have pt. move upper extremities 2. on command movements
3. Have pt. move lower extremities 3. on command movements
4. Test strength of upper extremities 4. weak grip bilaterally
5. Test strength of lower extremities 5. moves against gravity
6.Sensation upper extremities 6.to touch, pain
7.Sensation lower extremities 7.to touch, pain
8. GCS 8.7t

Evaluation of outcome objectives:

Goal met. Patient nod/shook head to yes/no questions and followed commands during my assessments.

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