Concept Map Template NURS 3073

Student Name:

Client: 53B Age: 68 DOA: Code status: Full Code Allergies: Contrast medium
Reason for hospitalization: Pneumonia
Priority assessments: Respiratory
Significant history: Decompensated cirrhosis (ascites), COPD, CAD, CABG, T2DM, HTN, BPH, open
cholecystomy, SBO, etOH abuse
Nursing diagnosis: Ineffective airway clearance related to tracheal bronchial inflammation secondary to
pneumonia

Supporting data: pneumonia, bilateral atelectasis, small right sided pleural effusion, increased sputum production
(yellow), decreased energy fatigue, decreased air entry bilaterally, crackles to bilateral bases, ++SOBOE, increased O2
requirements, frequent cough, ascites

Goals: Patient will maintain patent airway with breath sounds clearing and absence of dyspnea

Interventions
-assess rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles
- auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds
- observe the sputum color, viscosity, and odor
-apply oxygen as needed

Outcomes
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Nursing diagnosis: Impaired gas exchange related to inflammation and collection of fluid in alveoli secondary to
pneumonia and right pleural effusion

Supporting data: crackles to bases bilaterally, yellow sputum, decreased air entry bilaterally, increased O2
requirements (90% optiflow), SOBOE

Goals: Patient will maintain O2 sats above 90% on 45% 4LPM optiflow

Interventions
-Monitor and record vital signs
- Monitor respiratory rate, depth and rhythm
- Assess pt’s general condition
- Auscultate breath sounds, note areas of decreased/adventitious breath sounds as well as fremitus
- Elevate head of the pt.
- Note for presence of cyanosis
-Encourage frequent position changes and deep-breathing exercises
-Provide supplemental oxygen 2plm nasal cannula

Outcomes
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Nursing diagnosis: Excess fluid volume related to development of ascites secondary to hepatic cirrhosis

Supporting data: firm and distended abdomen, ++ abdominal pain, portal hypertension, consult for paracentesis, weigh
gain, intake greater than output, pleural effusion, edema to ankles
Goals Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within normal range,
and absence of edema.

Interventions
-daily weight
-measure input and output
-assess JVP and abdominal distension
-monitor electrolytes
Outcomes
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Diagnostics/lab data (Identify data most relevant to interventions/diagnosis above)
-PLT: 142