1

Key Problem
Prone for infection
Key Problem Supporting data
Impaired Gas Exchange Key Problem Uncontrolled type 2 diabetes
Supporting Data: Impaired Verbal Glucose (245 admission/ 297 now)
Acute Resp. Failure Communication WBC 12.1
Dyspnea/hyoxia Supporting data Tracheostomy
ABG: pH 7.33, PCO2 63.7, PO2 215, Tracheostomy but Peg tube
HC03 33 connected to Overweight
FiO2 .40 mechanical ventilation CAD
SPO2 80 when on spontaneous vent Able to speak very little UTI
RR 20 Use of pen and paper for Albumin 2.5
HGB (admission 11, now 8.3) communication Hx of anxiety + depression
Chronic Hypoxia Vancomycin IV
Chronic Pulmonary Fibrosis

Key Problem
Key Problem Excess Fluid Volume
Ineffective Airway Clearance Supporting data
Supporting data: Generalized edema +3
PT brought in d/t mucous plug Reason for Needing Health Care Recent ankle fracture—Immobile
thus becoming unconscious Pt. become unconscious after mucous plug. Cardiomyopathy
Coarse breathe sounds Acute Respiratory Failure, UTI, septic. Uncontrolled type 2 diabetes
Tracheostomy- requires Tracheostomy connected to A/C vent. Glucose (245 admission/ 297 now)
suctioning 73 y.o. female, full code Stage 3 Chronic Kidney disease
Turn q2hr Creatinine (1.8 admission/ .98
COPD Key data: Respiratory, fluid electrolyte and now)
WBC 26.6 cardiac focused BUN (26 admission/ 28 now)
Neutrophils 85 BNP 58.63
Vancomycin IV Allergies: Penicillin, atorvastatin, NA 134
cephalexin, clarithromycin, meperidine, K+ 4
UO < 25 mL in 1 hrs
Key Problem
Impaired Spontaneous Key Problem
Ventilation Poor cardiac output
Key Problem
Supporting data: Supporting data:
Anxiety
Pt. went from A/C to spontaneous Hx of CAD + cardiomyopathy
Supporting data:
vent Cardiac arrest within last 2
Pt asked for antianxiety med
and was not able to maintain SPO2 months
Stated anxiety was a 10
Acute Respiratory Failure Past echocardiogram EF <30%
using 0-10 scale
Diminished/coarse lung sounds Generalized edema
Appeared anxious
TV 400 SOB
Restless, feeling discomfort
FiO2 .40 AFIB w/ RVR
Ativan IV
Mode: A/C Pulse 2+
RR inc, face appeared flushed/red
Set RR: 14 BP: 119/45 (current)
when anxious
Peep: 5 MAP (69)
Weight: 118.1 Kg
Height: 1.57 m
BNP: 58.63
Troponin: 0.05

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

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Problem # __ Impaired gas exchange _____:

General Goal: Attain adequate gas exchange
Predicted Behavioral Outcome: Patient will be able to maintain an SPO2 between 88-93.
ABGs will be WDL. Will be able to switch to spontaneous ventilation by tomorrow.

Nursing Interventions Patient Responses

1. Position pt in semi fowlers 2. PT SPO2 was 100% with AC

2. Avoid high concentration 02 ventilation. Want to be 88-93.
(COPD pt) 3. SPO2 100%, ABG pH 7.33,
3. Assess ABGs + SPO2 PCO2 63.7, PO2 215, HC03 33
4. Check Hgb levels 4. HGB (admission 11, 8.3)
5. Monitor chest x-rays 5. Pulmonary opacities
6. Assess lungs + breathing patterns 6. Lung sounds were diminished
coarse. RR 20

1. Pts respirations were unlabored

promoting expansion

Evaluation of outcome objectives: Pt. SPO2 was 100 with AC. Waiting for an ABG redraw.
Pt. switched to Spontaneous ventilation. SPO2 dropped to 80 and was put back on AC. Goal
not met. On going.

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

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Problem # __ Ineffective Airway Clearance _____:

General Goal: Patient will maintain a clear airway.
Predicted Behavioral Outcome: Secretions will become more thin and clear. Lung sounds
will be clear, open airways as evidence by normal breath sounds, normal rate/ depth of
respirations.
Nursing Interventions Patient Responses

1. Assess for airway patency 2. Lung sounds coarse and

2. Auscultate lung sounds diminished
3. Suctioning prn 3. Pt. relieved by suction.
4. Monitor WBC Secretions thin and clear.
5. Vancomycin given 4. WBC 26.6
6. Provide oral care q 2 hrs 5. Vancomycin for infection
6. Pt. enjoyed. Done to prevent
hosp. acquired pneumonia
1. Airway patent. Pt. receiving
oxygen.

Evaluation of outcome objectives: Pt. SPO2 was 100 with AC. Waiting for an ABG redraw.
Pt. switched to Spontaneous ventilation. SPO2 dropped to 80 and was put back on AC. Goal
not met. On going.

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

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Problem # __ Impaired Spontaneous Ventilation _____:

General Goal: Pt. will demonstrate adequate ventilation
Predicted Behavioral Outcome: Pt. will have no complications and attain proper ventilation
on day of care

Nursing Interventions Patient Responses

1. Observe changes in LOC 1. Pt. was alert and oriented

2. Assess HR + BP 2. Pt. HR 84, BP 114/45
3. Monitor Oxygen saturation 3. SPO2 100% on AC ventilation
4. Assess vent. settings and 4. Settings are accurate and tube is
connections connected
5. Assess clients comfort 5. Client was very anxious and
Encourage deep breathing and appeared uncomfortable.
coughing 6. Pt. appeared less SOB and inc. in
mucus clearance

Evaluation of outcome objectives: Pt achieved adequate ventilation during shift. No

problems occurred except the drop is SPO2 when switch from AC to spontaneous
ventilation. Goal not met.

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

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Problem # __ Anxiety _____:

General Goal: Pt will be less anxious
Predicted Behavioral Outcome: Pt will rate anxiety <4 on a 0- 10 scale and appear more
relaxed by end of shift.

Nursing Interventions Patient Responses

1. Maintain a calm environment 2. Pt. felt comfortable

2. Establish trust with pt. communicating with me using
3. Provide reassurance and comfort pen and paper.
measures 3. Pt. appeared to like when I talked
4. Assess for an inc. in anxiety in a soft, calming tone.
5. Give antianxiety med prn 4. Pt. appeared anxious.
6. Encourage relaxation 5. Pt. still appeared anxious after
anxiety med was given.
6. She did well when I asked her to
1. Closed curtain when providing take a second and breathe in
care. through nose and out through
mouth.

Evaluation of outcome objectives: Did not meet. Patient was anxious and uncomfortable.
On going.

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

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Problem # Poor Cardiac Output _____:

General Goal: Maintain Proper Cardiac Output
Predicted Behavioral Outcome: Pt. will demonstrate adequate CO as evidence by BP, pulse,
and no sx of dyspnea or chest pain on day of care.

Nursing Interventions Patient Responses

1. Assess HR + BP 1. HR 84, BP 114/45

2. Check peripheral pulses 2. Pulses were 2+ bilaterally
3. Auscultate heart sounds 3. S1, S2 present
4. Check BNP + troponin levels 4. BNP 58.63, troponin
5. Assess skin 5. Skin is warm and dry
6. Cardiac monitor placement 6. Cardiac monitor was placed
appropriately

Evaluation of outcome objectives: Patient BP was lower. Pulses were good. No sx of chest
pain. Dyspnea r/t exertion, pain and anxiety. Goal partially met on shift.

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

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Problem # __ Excess Fluid Volume _____:

General Goal: Decrease fluid volume
Predicted Behavioral Outcome: Pt. will increase UO 30 mL > hr, lab values WDL, and
generalized edema will be <1 by the end of the day.

Nursing Interventions Patient Responses

1. Assess BP + Edema 1. BP 114.45 and generalized

2. Assess renal functioning edema 3+
3. Monitor fluid intake and output 2. BUN 28 and creatinine 1.8
4. Elevate extremities 3. Urine output 25 mL/hr
5. Assess lung sounds 4. Upper + lower extremities were
elevated on pillow.
5. Lung sounds course

Evaluation of outcome objectives: Pts UO did not increase above 25 mL/hr, creatine is
WDL and pt still has 2+ generalized edema. Partially met.

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

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Problem # __ Prone for infection _____:

General Goal: Pt. will remain free of infection
Predicted Behavioral Outcome: Pt. will have absence of S/S of infection. WBC will be
WDL by tomorrow.

Nursing Interventions Patient Responses

1. Assess for presence of local 2. Clear secretions

infection on skin 3. Solid BM. Brown in color. Felt
2. Note for color of resp. secretions impacted, enema was given.
3. Assess stool + Urine color/odor Urine yellow with some
4. Assess WBC sediment.
5. Provide oral hygiene 4. WBC 12.1- sign of infection
6. Assess/monitor nutrition 5. Pt. seemed more comfortable
after oral care.
6. Pt. albumin level is low at 2.5

1. Redness on bum. Antibiotic

ointment applied

Evaluation of outcome objectives: On going. Not met. Patient WBC is 12.1. Plan to draw more labs
tomorrow and assess.

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

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Problem # __ Impaired verbal communication _____:

General Goal: Achieve proper communications
Predicted Behavioral Outcome: Patient will be able to understand and communicate with the
nurse during the shift.

Nursing Interventions Patient Responses

1. Place important objects (call 1. Pt. was able to use call light
light) within reach 2. Pt. made grimaces when in
2. Learn patients nonverbals cues discomfort
3. Provide alternative version of 3. Pen and paper were provided.
communication Used well.
4. Clarify patient understanding 4. Pt. was aware of the situation
5. Speak in a normal, calm tone to 5. Pt. appeared to like my tone of
pt voice

Evaluation of outcome objectives: Goal was met. Patient was able to effectively communicate with
me and comprehensive of what needed to be done.

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