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Complex Care Concept Map

Kimberly Reinhart

Key Problem/ND: Ineffective Airway Key Problem/ND: Decreased Key Problem/ND: Impaired Tissue
Clearance Cardiac Perfusion Perfusion

Supporting Data: Supporting Data: Supporting Data:

-diminished breath sounds -anxiety -generalized weakness
-rhonchi in upper lobes -restlessness -tachycardia
-thick, white secretions -tachycardia -SpO2 98 w/FiO2 .50
-productive cough -tachypnea -capillary refill >3 seconds
-Ventolin Nebulizer -cool, clammy extremities
-Zosyn (piperacillin) IV
-Vancocin (Vancomycin) IV

Reason for Needing Health Care:

Respiratory Failure r/t Exacerbation of Key Problem/ND: Impaired
Key Problem/ND: Ineffective COPD Verbal Communication
Breathing Pattern 60 year old male, DNR-CCA
Supporting Data:
Supporting Data: Key Assessments: VS with focus on -intubated
-dyspnea cardiac and respiratory -assess cuff pressure
-cough -Diprovan (Propofol) IV
-tachypnea Allergies: aspirin, caffeine, orphenadrine, -Opens eyes to verbal command
-restlessness sertraline and when name is called
-inc pCO2 -hypercapnia

Key Problem/ND: Impaired Key Problem/ND: Impaired Gas Key Problem/ND: Anxiety
Spontaneous Ventilation Exchange
Supporting Data:
Supporting Data: Supporting Data: -facial tension
-pt is on ventilator -FiO2 .50 -restless
-SIMV mode -ABG’s pH 7.32 pCO2 57.5 pO2 110 -tachypnea
-Rate 14 -SpO2 98 -confusion
-FiO2 .50 -uncompensated respiratory acidosis
-TV 450mL -hx of COPD
-PEEP 5 -hypercapnia
-PSV 16
-dry oral mucous membranes (ET tube)
-mouth care q 2hrs

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

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Problem # 1:
General Goal: Client will maintain clear, open airways, as evidenced by normal breath sounds after suctioning

Predicted Behavioral Outcome Objective (s): The patient will maintain airway patency w/breath sounds
clear/clearing on the day of care

Nursing Interventions Patient Responses

1. Auscultate breath sounds and note

adventitious sounds 1. Pt had diminished breath sounds and rhonchi
in upper lobes
2. Monitor respirations 2. Pt had RR of 28 and shallow
3. Elevate HOB to open up airways 3. RR still inc with HOB elevated
4. ABGs showed resp. acidosis, pulse ox 98%,
4. Monitor ABGs, pulse ox, chest x-ray chest x-ray showed fluid in lungs
5. Turn pt q 2 hrs to prevent aspiration 5. Pt was turned q 2hrs which prevented him
from aspirating
6. Note presence of sputum and evaluate 6. Sputum was thick and white
amount, color, and consistency 7. Skin turgor was elastic
7. Assess hydration status

Evaluation of outcome objectives: Pt maintained airway but had diminished breath sounds in the upper lobes

Problem # 2:
General Goal: Decreased Cardiac Perfusion
Predicted Behavioral Outcome Objective (s): The patient will demonstrate adequate CO as evidenced by
blood pressure and pulse rate within normal parameters

on the day of care.

Nursing Interventions Patient Responses

1. Note skin color, temperature and moisture 1.

2. Check for alterations in level of consciousness 2.
3. Monitor ECG for rate and rhythm 3.
4. Assess oxygen saturation 4.
5. Note RR, rhythm and breath sounds 5.
6. Monitor I&O 6.
7. Examine ABGs and electrolytes (especially potassium) 7.

Evaluation of outcome objectives:

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

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Problem # _______:
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will……

on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.

Evaluation of outcome objectives:

Problem # _______:
General Goal:
Predicted Behavioral Outcome Objective (s): The patient will……

on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
Evaluation of outcome objectives:

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

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Problem # _______:
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will……

on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.

Evaluation of outcome objectives:

Problem # _______:
General Goal:
Predicted Behavioral Outcome Objective (s): The patient will……

on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
Evaluation of outcome objectives:

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

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Problem # _______:
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will……

on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.

Evaluation of outcome objectives:

Problem # _______:
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will……

on the day of care.

Nursing Interventions Patient Responses

1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
Evaluation of outcome objectives:

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