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Assessment and Concept Map Care Plan

Gina Bellotta

Clinical Instructor Heidi Alflen

Nurs 4840L

Youngstown State University

 Key Problem #1 2
Impaired Gas Exchange
Supporting Data
-Patient on 12L nasal cannula oxygen
-Was placed on BiPAP but did not
improve Key Problem #4
-Patient was intubated Impaired Verbal Communication
-ABG results on admission (2/16/20): pH: Supporting Data
7.40, PCO2: 67.8, PO2: 102, HCO3: 42 – -Patient presented with acute
Partially Compensated Respiratory respiratory distress and altered
Acidosis mental status
-ABG results on date of care: (2/18/20): -Patient was intubated after
pH: 7.36, PCO2: 93.2, PO2: 67, HCO3: 52 BiPAP was not beneficial
-Diminished breath sounds -Given propofol
-Hypoxia and hypercapnia

Key Problem #2 Reason for Needing Health Care

Ineffective Breathing Pattern Acute Respiratory Failure with Hypoxia
Supporting Data and Hypercapnia Key Problem # 5
-History of sleep apnea Key Assessments Excess Fluid Volume
-Diminished breath sounds Breath sounds, ABG’s, vital signs, Supporting Data
-History of COPD respiratory rate and depth, neurological -Patient is short of breath
-Increased PCO2 checks -Arrived with altered mental
-Placed on BiPAP Vital Signs status
-FiO2: 5% T: 98.4, BP: 123/79, MAP: 87, HR: 104, -Edema in lower extremities
-Chest X-ray showed vascular RR: 16, SPO2: 93% bilaterally
congestion and suggested small pleural ABG’s on Date of Care -Patient is on a diuretic (Lasix)
effusions pH: 7.36, PCO2: 93.2, PO2: 67, HCO3: 52 -Patient is tachycardic (HR: 104)
-Patient on a bronchodilator (Partially Compensated Respiratory
Acidosis)
No Known Drug Allergies
Full Code

Key Problem #3
Decreased Cardiac Output Key Problem #6
Supporting Data Key Problem #7
Ineffective Tissue Perfusion
-Patient became hypotensive when Activity Intolerance
Supporting Data
given propofol Supporting Data
-Abnormal blood gases
-History of heart failure -Mild weakness
-Hypervolemia
-History of A-fib and A-flutter -Patient is short of breath
-Altered mental status
-Patient is tachycardic with a HR of -Imbalanced oxygen supply and
-Mild weakness
104 demand due to inefficient work of
-Edema
-Irregular rhythm breathing
-Altered breathing
-Chest X-ray showed heart -Patient has a history of
-Shortness of breath
enlargement osteoarthritis
-Diminished breath sounds
-Patient is on Lopressor, Lanoxin, -Patient has a history of COPD and
and Cordarone heart failure
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Evaluation of Outcomes
Problem # 1 : Patient maintains gas exchange evidenced by usual mental status, unlabored respirations,
General Goal: normal oximetry, HR, and ABG’s

Predicted Behavioral Outcome Objective (s): The patient will remain oriented, maintain vital signs within a
normal range, and show less labored breathing on the day of care.

on the day of care.

Nursing Interventions Patient Responses

1. Elevate head of bed 1. Patient’s breathing is improved with

2. Nasal cannula oxygen head of bed elevated
3. BiPAP 2. Patient cooperates with nasal
4. Encourage and assist with deep cannula oxygen, SPO2 is 93%
breathing 3. BiPAP not effective, patient
5. Properly position patient intubated
6. Monitor vital signs 4. Patient can demonstrate deep
breathing
5. Patient position monitored and he
responds well to position changes
6. Vital signs remain within normal
range, SPO2 is a bit low and HR is a
bit elevated

Evaluation of outcome objectives: Patient struggles to maintain adequate O2 without administered oxygen and
has a very high CO2. Patient is drowsy and short of breath.

Problem # 2 : Patient maintains an effective breathing pattern, as evidenced by relaxed breathing at a

General Goal: normal rate and depth and absence of dyspnea.

Predicted Behavioral Outcome Objective (s): The patient’s respiratory rate remains within established limits
and ABG levels return to normal on the day of care.

Nursing Interventions Patient Responses

1. Administrate respiratory medications 1. Patient takes albuterol as scheduled

as indicated
2. Administer oxygen as indicated
3. Maintain a clear airway with coughing
and deep breathing
4. Encourage small frequent meals
5. Suction as necessary
2. Patient is ordered 12L of oxygen nasal cannula
3. Patient is able to demonstrate coughing and
deep breathing
4. Patient is on a cardiac diet
5. No suctioning was done during my shift

Evaluation of outcome objectives: Patient’s respiratory rate was 16 but his ABG levels were still presenting as
Partially Compensated Respiratory Acidosis and not within normal ranges.
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Evaluation of Outcomes
Problem # 3 : Patient demonstrates adequate cardiac output as demonstrated by blood pressure and pulse
General Goal: rate

Predicted Behavioral Outcome Objective (s): The patient’s blood pressure will be within normal limits and his
pulse rate will be within normal limits without any dysrhythmias on the day of care.

Nursing Interventions Patient Responses

1. Record intake and output 1. Patient is eliminating regularly, urine is clear
2. Limit fluid and sodium as ordered and pale yellow
3. Auscultate heart sounds 2. Patient follows a cardiac diet
4. Observe for and document any chest pain 3. Heart rhythm is irregular, but S1 and S2 are
5. Monitor ABG’s and electrolytes present
6. Examine chest X-ray 4. Patient does not report any chest pain
5. ABG’s are not within normal limits but
electrolytes appear normal
6. Chest X-ray showed an enlarged heart
Evaluation of outcome objectives: Patient’s blood pressure is within normal limits but the heart rate is 104 and
irregular.

Problem # 4 : Patient uses a form of communication to get needs met and to relate effectively with people
General Goal: and his environment.

Predicted Behavioral Outcome Objective (s): Patient needs will be met and understood through adequate
communication.

Nursing Interventions Patient Responses

1. Learn patient needs and pay attention to
non-verbal cues
2. Explain everything to patient and
inform patient before touching them
3. Keep distractions such as television and
radio at a minimum when speaking to
the patient
1. Patient needs were met throughout shift
2. Patient was well spoken to and it was always
made clear when they would be provided care
3. When the patient was spoken to, it was through
clear communication with no distractions

Evaluation of outcome objectives: Good communication was kept between medical staff and the patient.
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Evaluation of Outcomes
Problem # 5 : Patient will be normovolemic as evidenced by urine output greater than or equal to 30
General Goal: mL/hr

Predicted Behavioral Outcome Objective (s): Patient will demonstrate stabilized fluid volume with balanced
I/O, clear breath sounds, normal vital signs, and absence of edema during the shift.

Nursing Interventions Patient Responses

1. Limit sodium intake as prescribed 1. Patient follows a cardiac diet
2. Monitor fluid intake 2. Patient is taking in adequate fluid amount
3. Strict I/O 3. Patient is eliminating regularly
4. Take diuretics as indicated 4. Patient takes Lasix as scheduled
5. Assess BP and edema 5. Patient has edema in lower extremities but
but BP is within normal range

Evaluation of outcome objectives: Patient is taking diuretics and is eliminating regularly. Patient is exhibiting
balanced I/O, is short of breath, vital signs within normal limits except for a HR of 104, and still has edema in
lower extremities.

Problem # 6 : Patient maintains maximum tissue perfusion to vital organs, as evidenced by warm and dry
General Goal: skin, present and strong peripheral pulses, vitals within patient’s normal range, balanced
I&O, absence edema, normal ABGs, alert LOC, and absence of chest pain.

Predicted Behavioral Outcome Objective (s): Patient’s mental status will not worsen and he will have a
balanced I/O during this shift.
Nursing Interventions Patient Responses

1. Check respirations and absence of work
of breathing
2. Closely monitor BP, HR, and SPO2
3. Assess patient’s skin
4. Monitor I/O
5. Perform neurological exams frequently
1. Patient’s respiration rate is 16 but he is short of
breath
2. Vital signs are mostly stable, HR is tachy and
is only 93% with oxygen therapy
3. Patient’s skin is warm, moist, and elastic
4. Patient is urinating regularly and following diet
5. Patient tolerates neurological exams

Evaluation of outcome objectives: Patient’s skin is warm moist and elastic, vitals that are slightly abnormal are
a HR of 104 and SPO2 of 93% with oxygen therapy, pulses are present in all extremities, the patient has an
altered mental status, is drowsy and has garbled speech. ABG’s are out of normal range. Edema present in
lower extremities. No reports of chest pain.
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Evaluation of Outcomes
Problem # 7 : Patient will exhibit tolerance during physical activity.
General Goal:

Predicted Behavioral Outcome Objective (s): Patient will be able to tolerate coughing and deep breathing and
will remain well rested during this shift.

Nursing Interventions Patient Responses

1. Refrain from performing nonessential activities
or procedures
2. Assist patient with ADLs as needed
3. Encourage physical activity consistent with the
patient’s energy levels
4. Provide emotional support to patient and family
1. Patient remained resting
2. Patient tolerated assistance with necessary
activities
3. Patient was resting during my shift
4. Emotional support and therapeutic
communication was effective with patient

Evaluation of outcome objectives: Patient was able to demonstrate coughing and deep breathing and remained
well rested during the shift.