Concept Map

Jenna M. Spotts
Nur 321
Prof. Seaman

Patient admitted with a COPD exacerbation

History of Present Illness

1 day history of SOB, continued having SOB after using portable O2. Cough with
mostly white but intermittently yellow sputum. Denies chest congestion. Had nebulizer
treatment, but still had SOB and wheezing.
Past Medical History
ESRD, seizure disorder, HIV, COPD, HTN, Hep C, hx of CVA, thromboembolism (s/p IVC
filter), CLL/SLL, cirrhosis, pulmonary TB, subacute lymphoid leukemia, hypermetabolic
liver masses, subacute frontal lobe infarct, chronic anemia, nephrotic range
proteinuria, CAD (nonobstructing), multiple superficial LE venous thrombosis,
pulmonary HTN, GERD, lipodystrophyabd lypohypertrophy, hypercholesteremia, HSV
1, small left renal cyst, splenic infarct, erectile dysfunction, herpes zoster, diastolic
CHF
Past Surgical History
Epididymo-orchitisRight 12/2012
Diagnostic Tests
Right colon avid uptake on PET/CT
EKG (9/27/2014)sinus tachycardia, inferior infarct
Chest Portable (927/2014)hx of SOB, no active disease. Stable calcified mass
medially in the LUL, no internal change.
NM Pulmonary Perfusion Quant with Imaging (9/28/2014)ordered, no result during
clinical day

Jenna M. Spotts

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Medications
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.

Pantoprazole (40mg/RXQD7/PO)GERD
IVSL Flush with NSS (RXQ8H)
Ipratropium Bromide (3mL/QID/IH)bronchodilator for COPD
Hydroxyzine HCL (25mg/RXQ8H/PO)anxiety
Darunavir Ethanolate (600mg/RXBIDCC/PO)HIV
Etravirine (200mg/RXBIDCC/PO)HIV
Heparin Na (5000units/RXQ12H/SQ)DVT prophylaxis
Methylprednisolone (40mg/RXQD/PO)COPD
Hydrochlorothiazide (25mg/RXQD/PO)HTN/CHF
Fluticasone Propionate (2 sprays/RXQD/Nasal)COPD
Multivitamins (1 tab/RXQD/PO)vitamin deficiency
Aspirin (325mg/RXQD/PO)antiplatelet
Tiotropium Bromide (18mcg/RXQD/IH)COPD
Risperidone (0.25mg/RXBID/PO)depression
Clopidogrel Bisulfate (75mg/RXQD/PO)antiplatelet
Sertraline HCl (50mg/RXQD/PO)depression
Lamivudine (50mg/RXQD/PO)HIV
Ritonavir (100mg/RXBID/PO)HIV
Teach Back Day 2 CHF
Acetominaphen (650mg/RXQ6H)PRN
Docusate Na (100mg/RXBID)PRN
Temazepam (15mg/RXHS)PRN

Jenna M. Spotts

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Lab Values
1. HgB (12.5-17.0g/dL)L at 11.0g/dLanemia, ESRD, cirrhosis
2. HcT (37-48%)L at 33.3%anemia, cirrhosis, ESRD
3. RBC (4-5.4mill/cmm^3)L at 3.66mill/cmm^3ESRD

4. BUN (7-28mg/dL)H at 36mg/dLCHF, ESRD

5. Creatinine (0.53-1.2mg/dL)H at 8.59mg/dLCHF, ESRD
6. Sodium (135-144mmol/L)L at 132mmol/LCHF, diuretics
7. Chlorine (100-109mmol/L)L at 93mmol/LCHF
8. GFR (>=60, with renal failure <15)L at 6ESRD
9. Phosphorus (2.3-4.6mg/dL)H at 5.1mg/dLESRD
10.Total Protein (6.3-8.0g/dL)H at 9.1g/dLESRD, cirrhosis
11.Total Alkaline Phosphate (35-120U/L)H at 125stress, anemia
12.Troponin 1 (<0.05ng/mL)H at 0.12ng/mLMI, minor myocardial
damage
13.Troponin 2 (<0.05ng/mL)H at 0.08ng/mLMI, minor myocardial
damage
14.Troponin 3 (<0.05ng/mL)H at 0.05ng/mLMI, minor myocardial
damage
Jenna
M. Spotts
Concept Map
15.NT-proBNP (<125pg/mL)H at 4722pg/mLcirrhosis, ESRD, MI,

Diagnostic Studies
1. EKG (9/27/2014)showed sinus tachycardia and inferior infarct.
2. Chest portable (9/27/2014)hx of SOBshowed no active
disease. Stable calcified mass medially in the LUL. No interval
change.
3. NM Pulmonary Perfusion Quant with imaging (9/28/2014
ordered, no results on the day on care.

Jenna M. Spotts

Concept Map

Stressors
Interpersonal

Pt finds it difficult to
communitcate with his wife
about his feelings.
Pt has a relationship that is
strained with his children from
his past.
Pt doesnt really know how to be
a father to his children. Due to
this he is trying to be a good
grandfather.
Pt had a bad relationship with
his ex wife which hurt his
relationship with his children.

Intrapersonal

Jenna M. Spotts

Pt is angry at himself
because he wasnt a father
to his children.
Pt is angry over his past
choices of abusing drugs.
Pt is trying to learn to
communicate but still finds it
to be difficult.
Pt is upset that he is still
smoking.
Pt is upset with himself, he
thinks he hurts his wifes
emotions and he doesnt
know how to overcome that
feeling.
Pt has a lot of disease
processes going on with his
body.
Pt is concerned about his
breathing.

Extrapersonal
Pt is retired.
Pts wife is in the hospital at the
same time as him.
Pt never went without a job but
bounced from job to job.
Pt wasnt reliable with his jobs
because of his drug use.
Pt didnt save money when he
was younger because of his
drug use.

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Assessment Data

Nursing
Diagnosis 1

Pt is a smoker, has bronchospasms, expiratory &

inspiratory wheezing, fatigue, dyspnea, cough
with some yellow mucous production, COPD,
nebulizer treatment, 2L oxygen, pt has oxygen at
home, pt states I still cant catch my breath.
Chest portable done, showed no active disease.
Stable calcified mass medially in LUL.

Nursing
Diagnosis 2

Pt has high blood pressure of 140/68, pt stated

it worries me that my BP is high, EKG showed
sinus tachycardia and inferior infarct, increased
troponin levels, increased BUN levels,
decreased sodium levels, increased creatinine
levels, decreased chlorine levels, increased BNP
levels. Hx of CVA, CAD, diastolic CHF.

Nursing
Diagnosis 3

Jenna M. Spotts

Pt is a smoker, has ESRD, substance abuse,

my drug of choice was heroin, high blood
pressure, low levels of HgB, HcT, RBC, GFR,
high levels of BUN, creatinine, phosphorus, total
protein, and BNP levels, pt has an LUE AV graft.
Pt is on a renal diet. Pt has dialysis 3 days a
week.

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Nursing Diagnoses

11

Impaired gas exchange R/T bronchospasm, smoker, fatigue, disease process AEB dyspnea, inspiratory
and expiratory wheezing, cough with some yellow mucous production, pt statement I still cant catch my
breath, pt is on 2L of oxygen, has oxygen at home, chest portable done showed there is a stable
calcified mass in the LUL, has a nebulizer treatment.

Decreased cardiac output R/T ineffective pump mechanism of left ventricle AEB high blood pressure,
EKG showed sinus tachycardia & inferior infarct, increased troponin levels, increased BNP levels,
increased BUN levels, increased creatinine levels, decreased sodium levels, decreased chloride levels,
pt stated it worries me that my blood pressure is high.

Ineffective renal perfusion R/T kidney disease process, smoking, substance abuse, increased blood
pressure AEB lab values of decreased HgB, decreased HcT, decreased RBC, decreased GFR,
increased BUN, increased phosphorus, increased total protein, increased BNP levels, pt stated my
drug of choice was heroin.

Jenna M. Spotts

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Interventions for Impaired Gas Exchange

1
2

Monitor
Monitor vital
vital signs:
signs: temperature,
temperature, blood
blood pressure,
pressure, heart
heart rate
rate
and
rhythm.
(Independent)
(Doenges,
Moorhouse,
&
Murr,
and rhythm. (Independent) (Doenges, Moorhouse, & Murr,
2013)
2013)
Encourage
Encourage frequent
frequent position
position changes,
changes, deep-breathing
deep-breathing
exercises
or
directed
coughing,
use
of
incentive-spirometer,
exercises or directed coughing, use of incentive-spirometer,
and
and chest
chest physiotherapy.
physiotherapy. (Independent)
(Independent) (Doenges
(Doenges et
et al
al 2013)
2013)
Administer
Administer medications
medications as
as indicated
indicated (inhaled
(inhaled and
and systemic
systemic
glucocorticosteroids,
glucocorticosteroids, antibiotics,
antibiotics, bronchodilators,
bronchodilators,
methylxanthanines,
methylxanthanines, antitussives,
antitussives, mucolytics,
mucolytics, vasodilators).
vasodilators).
Medications
may
be
aerolized
or
nebulized
Medications may be aerolized or nebulized for
for enhanced
enhanced
response
response and
and limitation
limitation of
of side
side effects.
effects. (Collaborative)
(Collaborative)
(Doenges
(Doenges et
et al
al 2013)
2013)
Provide
Provide supplemental
supplemental oxygen
oxygen (via
(via cannula,
cannula, mask)
mask) using
using
lowest
lowest concentration
concentration possible.
possible. (Independent)
(Independent) (Doenges
(Doenges et
et al
al
2013)
2013)
Provide
Provide psychological
psychological support,
support, active
active listen
listen questions
questions and
and
concerns.
Address
clients
fears
and
anxiety
concerns. Address clients fears and anxiety that
that may
may be
be
present.
present. Maintain
Maintain calm
calm attitude
attitude while
while working
working with
with client.
client.
(Independent)
(Independent) (Doenges
(Doenges et
et al
al 2013)
2013)

Jenna M. Spotts

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Rationales for Impaired Gas Exchange

Intervention #1high fever

greatly increases metabolic
demands and o2
consumption. BP can be
variable, depending on
underlying condition and
cardiopulmonary response.
Tachycardia and
dysrhythmias may be noted
as heart reacts to cardiac
ischemia and/or hypoxemia,
especially during activity.
(Doenges et al 2013)

Jenna M. Spotts

Intervention #2promotes
optimal chest expansion,
mobilization of secretions,
and oxygen diffusion.
(Doenges et al 2013)

Intervention #3
pharmacological agents are
varied, specific to the client,
but generally used to
prevent and control
symptoms, reduce
frequency and severity of
exacerbations, and improve
exercise tolerance.
(Doenges et al 2013)

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Rationales for Impaired Gas Exchange

Intervention #4dictated by
pulse oximetry, ABGs, and
patient symptoms/underlying
conditions. (Doenges et al
2013)

Jenna M. Spotts

Intervention #5anxiety is
contagious, and associated
agitation can increase
oxygen consumption and
dyspnea. (Doenges et al
2013)

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Interventions for Decreased Cardiac

Output

Teach
Teach the
the patient
patient about
about their
their condition,
condition, medication,
medication, and
and
management
plan.
(Independent)
(Butler,
2012)
management plan. (Independent) (Butler, 2012)

Lifestyle
Lifestyle should
should be
be assessed
assessed and
and changes
changes should
should be
be made
made
where
necessary;
smoking
cessation,
dietary
modifications,
where necessary; smoking cessation, dietary modifications,
minimal
minimal alcohol
alcohol consumption.
consumption. (Independent)
(Independent) (Butler,
(Butler, 2012)
2012)

5
6

Discuss
Discuss significant
significant signs
signs and
and symptoms
symptoms that
that need
need to
to be
be
reported
to
the
healthcare
provider.
(Independent)
(Doenges
reported to the healthcare provider. (Independent) (Doenges
et
et al
al 2013)
2013)
Administer
Administer pharmacological
pharmacological medications
medications such
such as
as diuretics,
diuretics,
ACE
ACE inhibitors,
inhibitors, ARBs,
ARBs, beta
beta blockers,
blockers, aldosterone
aldosterone
antagonists,
antagonists, aspirin,
aspirin, anticoagulants,
anticoagulants, vasodilators,
vasodilators, and
and
digoxin.
(Collaborative)
(Butler
2012)
digoxin. (Collaborative) (Butler 2012)
Encourage
Encourage changing
changing positions
positions slowly,
slowly, dangling
dangling legs
legs over
over the
the
bed
bed before
before standing.
standing. (Independent)
(Independent) (Doenges
(Doenges et
et al
al 2013)
2013)
Teach
Teach patient
patient about
about weight
weight management
management with
with decreased
decreased
cardiac
output.
Inform
the
patient
they
may
need
cardiac output. Inform the patient they may need aa fluid
fluid
restriction
restriction and
and to
to report
report anything
anything over
over 2lb/day.
2lb/day. (Independent)
(Independent)
(Butler,
(Butler, 2012)
2012)

Jenna M. Spotts

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Rationales for Decreased Cardiac

Output

Intervention #1pt is often

on multiple medications,
which can be difficult to
manage, thus increasing the
potential that medications
can be missed or incorrectly
used. (Doenges et al 2013)

Jenna M. Spotts

Intervention #2smoking is
a vasoconstrictor, alcohol is
a myocardial depressant,
and salt in the diet increases
fluid retention (should be
limited to < 3g/day.
(Doenges et al 2013)

Intervention # 3unrelieved
or increased chest pain,
dyspnea, fever, swelling of
ankles, and sudden
unexplained coughthese
are all danger signs that
require immediate evaluation
and possible change of usual
therapy. (Doenges et al
2013)

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Rationales for Decreased Cardiac

Output

Intervention #4helps to
alleviate symptoms, enhance
quality of life, and improve
life expectancy. (Butler,
2012)

Jenna M. Spotts

Intervention #5to reduce

risk of orthostatic
hypotension. (Doenges et al
2013)

Intervention #6those with

an accumulation of lfuid may
need to restrict fluid intake
with supervision from a
healthcare provide if their
symptoms are severe.
(Butler, 2012)

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Interventions for Ineffective Renal

Perfusion

Review lab studies (CBC, BUN/Cr levels, protein, specific

gravity, 24-hour creatinine clearance, glucose, electrolytes).
(Independent) (Doenges et al 2013)

Monitor fluid intake, urine output, and weight on a regular

schedule. (Independent) (Doenges et al 2013)

Discuss clients history of and current alcohol and illicit

substance abuse/use. (Independent) (Doenges et al 2013)

Administer medications (vasoactive medications, including

antihypertensives, diuretics, steroids, insulin) as indicated.
(Collaborative) (Doenges et al 2013)

Provide for fluid and diet restrictions, as indicated, while

providing adequate calories and hydration. (Independent)
(Doenges et al 2013)

Encourage client to quit smoking, join Smoke-out, or other

smoking-cessation programs. (Independent) (Doenges et al
2013)

Jenna M. Spotts

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Rationales for Ineffective Renal

Perfusion

Intervention #1to assess

status of renal function;
evaluate progression of renal
dysfunction or failureand
effects on body and organ
functions. (Doenges et al
2013)

Jenna M. Spotts

Intervention #2changes in
weight & fluid intake,
especially when calculated
against output on a regular
basis (24 hr) can provide
noninvasive assessment of
cardiovascular and renal
function. (Doenges et al
2013)

Intervention #3most street

drugs, including heroin,
cocaine, & ecstasy can
cause high blood pressure, a
risk factor for impaired renal
function. Alcohol, cocaine,
heroin, and amphetamines
also can cause kidney
damage. (Doenges et al
2013)

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Rationales for Ineffective Renal

Perfusion

Intervention #4to treat

underlying condition and
improved renal blood flow
and function. (Doenges et al
2013)

Jenna M. Spotts

Intervention #5to meet the

bodys needs without
overtaxing kidney function.
(Doenges et al 2013)

Intervention #6smoking
causes vasoconstriction,
potentially compromising
renal perfusion. (Doenges et
al 2013)

Concept Map

Outcomes and Goals

Impaired Gas Exchange

1.
2.
3.
4.

Patient will return to baseline function with appropriate treatment and monitoring of his chronic
lung disease on the day of care. (Tabloski, 2010)
Patient will participate in treatment regimen within level of ability on the day of care. (Doenges
et al 2013)
Patient will remain calm and anxiety free on the day of care. (Doenges et al 2013)
Patient will experience adequate O2/CO2 exchange on the day of care. (Saunders, 2012)

Jenna M. Spotts

Concept Map

Outcomes and Goals

Decreased Cardiac Output

1.
2.
3.
4.

Patient will participate in the learning process about medications and heart failure on the day of
care. (Doenges et al 2013)
Patient will participate in activities that reduce the workload of the heart (stress management,
weight reduction, balanced activity/rest plan, proper use of supplemental oxygen, cessation of
smoking) on the day of care. (Doenges et al 2013)
Patient will identify the signs and symptoms that are considered danger signs on the day of
care. (Doenges et al 2013)
Patient will display hemodynamic stability (blood pressure, peripheral pulses) on the day of
care. (Doenges et al 2013)

Jenna M. Spotts

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Outcomes and Goals

Ineffective Renal Perfusion

1.
2.
3.

Patient will engage in behaviors or lifestyle changes to improve circulation (smoking cessation,
medication management) on the day of care. (Doenges et al 2013)
Patient will verbalize understanding of condition, therapy regimen, side effects of medications,
and when to notify healthcare provider on the day of care. (Doenges et al 2013)
Patient will demonstrate increased perfusion as individually appropriate (skin warm and dry,
peripheral pulses are present and strong, absence of edema, free of pain or discomfort on the
day of care. (Doenges et al 2013)

Jenna M. Spotts

Concept Map

Evaluations and Recommendations

Impaired Gas Exchange
Patient had respirations of 16
on the day of care, and a pulse
oximetry of 100% on the day of
care. Patient was still wearing
the nasal cannula.
Talked to patient about using an
incentive spirometer and deep
breathing exercises. Patient was
interested in the deep breathing
and was able to show the
student nurse the exercises.
Focused on talking with the
patient about his life and gave
him some tips to relieve the
anxiety and anger. Patient
remained calm.
Patient still noted some SOB,
lungs had inspiratory and
expiratory wheezes, patient
didnt have labored breathing.

Jenna M. Spotts

Decreased Cardiac Output

Patient participated in the

teach back that was done
however a lot of the
information pertained to
ESRD, patient was
interested in learning more
and requested a CHF book
which was given to him
along with a pamphlet about
his medications.
Patient was taught about
quitting smoking and even
agreed to a smoking
cessation consult.
Patient was taught about the
danger signs and verbalized
his understandings that he
needed to report them
immediately.

Ineffective Renal Perfusion

Patient and student nurse had a
conversations about smoking
and patient agreed to a smoking
cessation consult. Patient
verbalized that he needed to
walk more and that he
understands it helps to improve
circulation.
Patient verbalized that he has
dialysis 3x/week. Patient was
given a booklet with his
medications in it, patient
verbalized his understanding of
the regimen and side effects.
Patient was wearing a robe
while sitting up in bed, pulses
were palpable and strong, skin
was warm to the touch, no
edema, patient had pain from
previous injury, color was even
throughout.

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References
1. Butler, J. (2012). Nursing Practice. An Overview of Chronic Heart Failure
Management, 108 (14), 16-20.
2. Doenges, M., Moorhouse, M., & Murr, A. (2013). Nursing Diagnosis Manual
(4th ed., pp. 132-138, 343-348, 641-644). Philadelphia: F.A. Davis
Company.
3. Saunders. (2012, January 1). Nursing Diagnosis: Impaired Gas Exchange.
Retrieved October 11, 2014, from
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm ?
did=248
4. Tabloski, P. (2010). The Respiratory System. In Gerontological Nursing (2nd
ed., pp. 534-535). New Jersey: Pearson Education.

Jenna M. Spotts

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