Alexis Hertz

CC Concept Map

Calcagni
 Key Problem/ND
Key Problems/ND
Impaired Gas Exchange Key Problem/ND
Readiness for Enhanced
Supporting Data: Impaired Urinary
Family Coping
Minimal pleural effusion & Elimination
#1 #8 Supporting data: #5
atelectasis Supporting data:
DNR-CCA DNR-CC
O2 via NC 3LPM BUN 60H (admission)
End of life care
ABGs pH 7.405 PCO2 46.2H Creatinine 2.1H
ESRD
PO2 69.7 HCO3 28.3 UTI
End stage CHF
Compensated metabolic alkalosis Anuria (8ml in 6hr)
Responds to painful stimuli
SpO2 100% (with NC 3 LPM) CVVDH
Incomprehensible speech
Lethargy reported by nursing ESRD
Lethargy
home Foley
Decreased cardiac output
Hx CHF Brown/green urine w/
BP 87/53
Pulmonary vascular congestion sediment
MAP 63
and edema Hx CHF
CVVHD + vasopressors
Decreased urinary output (8ml in Imbalanced nutrition
Key Problem/ND:
Decreased Cardiac Output 6 hrs)
Supporting Data:
BP 87/53
#2 MAP 65 #7
HR 120 Key Problem/ND
Hx angioplasty with stent Imbalanced Nutrition:
Hx CHF, HTN, CAD Less than body
Hx A-fib w/ RVR Reason For Needing Health Care requirements
L subclavian pacemaker (Medical Dx/ Surgery) Supporting Data:
BNP 12441H Acute on chronic kidney failure Albumin 3.2L
Alk Phos 114H Acute on chronic systolic/diastolic CHF Total protein 5.6L
ALT 72H 67 y.o. female, DNR-CCA DNR-CC Phosphate 2.3L
AST 95H Creatinine 2.1H
Neo-synephrine (phenylephrine) Key Assessments: Hx diabetes (BS 139)
IV VS with focus on cardiac and renal Potassium 3.2L (admission)
Midodrine NG NG left naris
Hx hyperlipidemia Allergies: Erythromycin, Niaspan, PCN From nursing home
Confusion/lethargy
Key Problem/ND Altered mental status
Excess Fluid Volume
Supporting Data:
#4 Generalized +3 pitting edema #3 Key Problem/ND #6 Key Problem/ND
Anasarca/weeping Altered Renal Tissue Perfusion Hypothermia
BNP 12441H (Fluid excess) Supporting data: Supporting data:
Phosphate 2.3L BUN 60H (admission) Temp 97.6
Albumin 3.2L Creatinine 2.1H BP 87/53
Total protein 5.6L H/H 9.6L/31.5L Bair Hugger
Alk phos 114H BP 87/53 HR 120
AST 95H MAP 65 Shiver
H/H 9.6/31.5 (hemodilution) Anuria (8ml in 6hr) Anasarca/weeping
BP 87/53 Generalized edema (+3 pitting) (evaporation)
Foley (brownish/green with Pulmonary congestion CVVHD
sediment) Hx HTN Lethargy/confusion
CVVDH Hx CHF RR 22
Chest XR: vascular congestion, Compensated metabolc alkalosis
pulmonary edema, cardiomegaly Altered mental status
CVVHD
Step 4: Identification of goals, outcomes and interventions.

Step 5: Evaluation of Outcomes

Problem # 1: Impaired Gas Exchange
General Goal: Increase Gas Exchange

Predicted Behavioral Outcome Objective (s): SpO2 will remain >96% this shift with clear breath sounds

Nursing Interventions Patient Responses

1. Auscultate breath sounds q2hr 1. All lobes clear, diminished

2. Elevate HOB 30-40 2. SpO2 100%
3. Administer O2 as orderedNC 3. SpO2 100%
3LPM 4. ABGs pH 7.405 PCO2 46.2H PO2
4. Assess ABGs 69.7 HCO3 28.3 Compensated
5. Assess a.m. chest XR metabolic alkalosis
5. Minimal atelectasis and pleural
effusions
 4

Evaluation of outcome objectives: Goal met- pt remained at 100% SpO2 the entire shift

Problem # 2: Decreased Cardiac Output

General Goal: Maintain Adequate Cardiac Output

Predicted Behavioral Outcome Objective (s): The patient willremain NSR, vital signs WDL, at least
30ml/hr urinary output
on the day of care.
Nursing Interventions Patient Responses

1. Assess VS qhr 1. Temp 97.6 BP 87/53 MAP 65 HR 120

RR 22
2. Monitor ECG 2. HR 120 (tachycardia) A-fib RVR w/
IVCD (BBB)
3. Administer phenylephrine 39ml/hr 3. BP 87/53 MAP 65
4. Administer sodium citrate 50ml/hr 4. PT 45.4H INR 4.0
5. Monitor I&O qhr 5. 6hr intake: 1246 6hr output: 1018
(CVVHD)
6. Elevate legs to improve venous return 6. BP 87/53

Evaluation of outcome objectives: Goal not met- pts cardiac output did not improve over the course of care

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

 5

Step 5: Evaluation of Outcomes

Problem # 3: Altered Renal Tissue Perfusion
General Goal: Improve Renal Tissue Perfusion

Predicted Behavioral Outcome Objective (s): The patient will have increased renal tissue perfusion
evidenced by SBP >90, BUN and creatinine WDL, and urinary output of 30ml/hr
on the day of care.

Nursing Interventions Patient Responses

1. Monitor VS qhr 1. Temp 97.6 BP 87/53 MAP 65 HR

2. Monitor I&O qhr 120 RR 22
3. Assess BUN and creatinine levels 2. 6hr intake: 1246 6hr output: 1018
4. Administer CVVHD 3. BUN 21 creatinine 2.1H
5. Administer phenylephrine 39ml/hr 4. BP 87/53 MAP 65
6. Administer O2 NC 3LPM 5. BP 87/53 MAP 65
7. Assess urine 6. SpO2 100%
7. Brown/greenish, sediment noted

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

 6

Evaluation of outcome objectives: Goal not met- SBP 87, BUN did decrease from previous shift, creatinine
remained elevated, urine output of 8ml in 6hr, CVVHD administered as ordered

Problem # 4: Excess Fluid Volume

General Goal: Balanced Fluid Volume

Predicted Behavioral Outcome Objective (s): The patient will stay within parameters set by physician (0
or equal fluid balance) while on CVVHD, electrolytes will remain WDL, and maintain a MAP greater than 63
on the day of care.
Nursing Interventions Patient Responses

1. Assess I&O qhr 1. 166ml/hr IV intake, 8ml urine output

(6hrs)
2. Reduce rate of ultrafiltration during
CVVHD as indicated 2. -50 off thru CVVHD/hr0 off/hr
3. Monitor BP,MAP, HR qhr 3. BP 87/53 MAP 65 HR 120
4. Administer phenylephrine 39ml/hr
Administer midodrine 10mg 4. BP 87/53 MAP 65
5. Monitor serum electrolyte levels 5. Calcium 10.8H (calcium chloride)
6. Monitor PT and INR 6. PT 45.2H INR 4.0
7. Monitor and assess JDV 7. HOB elevated to 45, JVD noted

Evaluation of outcome objectives: goal met- pt remained in correct fluid balance as indicated by the
physician, electrolytes remained in balance, no intervention needed, and MAP remained over 63 for the shift

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

 7

Step 5: Evaluation of Outcomes

Problem # 5: Impaired Urinary Elimination
General Goal: Improved Urinary Elimination

Predicted Behavioral Outcome Objective (s): The patient will increase urinary output to 30ml/hr

on the day of care.

Nursing Interventions Patient Responses

1. Monitor VS 1. Temp 97.6 BP 87/53 MAP 65 HR

2. Assess I&O 120 RR 22
3. Assess urine 2. 8ml/6hr
4. Assess BUN and creatinine 3. Brown/greenish with sediment
5. Assess foley 4. BUN 21 creatinine 2.1H
6. Assess fluid balance 6. CVVHD 6hr intake: 1246 6hr
output: 1018

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

 8

Evaluation of outcome objectives: Goal not met-pt on CVVHD, urinary output of 8ml/6hr

Problem # 6: Hypothermia
General Goal:

Predicted Behavioral Outcome Objective (s): Patients temperature will remain >96.8

on the day of care.

Nursing Interventions Patient Responses

1. Assess temp q2hr 1. Temp 97.6

2. Assess HR and BP 2. BP 87/53 HR 120
3. Assess room temp q2hr (between 70-74) 3. Temp 97.6
4. Bair hugger per protocol 4. Temp 97.6
5. Use of blankets 5. Temp 97.6

Evaluation of outcome objectives: goal met- pts temp 97.6, will continue to monitor d/t
hypotension/decreased cardiac output

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

 9

Step 5: Evaluation of Outcomes

Problem # 7: Imbalanced Nutrition: Less than Body Requirements
General Goal: Improved Nutritional Status

Predicted Behavioral Outcome Objective (s): The patient will have <100 ml residual and serum lab
values WDL
on the day of care.

Nursing Interventions Patient Responses

1. Assess GI status 1. NPO, abdomen distended

2. Assess NG placement with air 2. Air bolus heard over abdomen
bolus PRN 3. 0ml of residual
3. Asses residual q4hr 4. Albumin 3.2L total protein 5.6L
4. Monitor labs, administer phosphate 2.3L
electrolytes per protocol 5. Abdominal distention unchanged
5. Elevate HOB 30 degrees 6. No BM during shift
6. Assess stool, color, amount,
consistency

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

 Evaluation of outcome objectives: Goal not met- pts lab values for albumin, total protein, and phosphate
remained low, however all other electrolytes remained in range, with 0ml residual

Problem # 8: Readiness for Enhanced Family Coping

General Goal: Improved Family Coping

Predicted Behavioral Outcome Objective (s): The patients family will state plan for the pt and her care
following a poor prognosis

on the day of care.

Nursing Interventions Patient Responses

1. Assess coping abilities of family 1. Visiting to cope with impending death

2. Establish rapport with family 2. Family felt comforted and reassured
with communication
3. Offer religious/spiritual support 3. Anointed
4. Assess for s/s of altered family process 4. Appropriate decision making to DNR-
CC
5. Assist family members to progress thru
their own grieving process 5. Responded well to offered help

Evaluation of outcome objectives: Goal met- family decided to change code status to DNR-CC and
demonstrated participation in health care decisions by the end of the day of care