Clinical Care Concept Map - Respiratory

Idaho State University
College of Technology; Associate Degree Registered Nurse Program

Clinical Care Concept Map
Respiratory
Student:
Preceptor:
Date(s) of Care: 006
Unit/Facility:
Age: 81
Gender: Female
Code Status: Full Code
Allergies: Gemfibrozil, Compazine, and Cardizem
Date of Admission: 1/18/2006
Current Medical Diagnosis: Pneumonia with Chest Pain/Fatigue
Pernicious Anemia
Surgical Procedure/Date: NA
Usual diagnostic labs, tests for this type of pathophysiology:
Pneumonia: - History and Physical Examination

Fatigue - Vital Signs
- Gram stain of sputum and blood cultures
- Sputum culture and sensitivity test
- Comprehensive Metabolic Panel (CMP) including AST/SGOT; ALT/SGPT;
Ca2+; ALK PHOS; Creatinine; Glucose; BUN; T Protein; Albumin; GLOB;
Na+; K+; Cl-, CO2-
- EKG for baseline
- CXR
Chest Pain: - EKG for baseline

- Cardiac Enzymes
Client/Family History that directly relates to this problem cluster:
Client reports family history of diabetes; heart disease; and cancer. No family history of kidney
disease; respiratory disease; epilepsy; hypertension; bleeding tendencies; or nervous disorders.
Mother and father deceased. Current spouse healthy and well but does have history of CVA
within the last year. Personal history includes appendectomy at age 5; and breast lumpectomy and
thyroid removal at age 40. Client also reports some history of high cholesterol and some
“asthma,” for which she is prescribed a bronchodilator (Xopenex) but it is rarely used.
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Health care perceptions practices & concerns (should include cultural and lifespan considerations):
Client reports that she is usually very healthy, tries to eat right, and is very active taking care of
her “grandbaby.” She is currently actively sitting one child approximately 18 months old “that
really keeps me moving. She always likes to play with grandma.”
Client reports no other health concerns. Eager to get back to taking care of grandchild, but
recognizes that she probably needs some rest.
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Date Diagnostics Results/Normal Range Significance: Why is this significant to patients’ outcome?
What nursing interventions are implicated?
1/18/2006 BMP The BMP is a broad screening tool to evaluate organ function and check for conditions such as
21:55 CALCIUM 8.5 mg/dL (8.5 – 10.6) diabetes, liver disease, and kidney disease; to monitor for known conditions such as hypertension; and
CREATININE (R) 1.4 mg/dL (0.7 – 1.4) to monitor medications for kidney and liver side effects.
GLUCOSE 123 mg/dL (64 -112)
BUN 21.2 mg/dL (5.0 – 23.0) Glucose – basic energy source for cells
NA+ 139 mmol/L (138 - 151) Electrolytes - Ca2+; Na+; K+; Cl- - various disease states; acid base balances
K+ 3.8 mmol/L (3.7 – 5.2) BUN (blood urea nitrogen) and Creatinine – state of kidneys
CL- 105 mmol/L (98 – 113)
CO2- 19.3 mmol/L (23.0 – 34.0) For this patient, the glucose is slightly high and the CO2- is slightly low. CO2- level may be due to
reduced respiratory capacity.
1/18/2006 CARDIAC PANEL The Cardiac Panel tests are performed to help diagnose a client AMI.
21:55 CKMB (TRIAGE) 1.4 ng/ml (0.0 – 4.3)
MYOGLOBIN 479.0 ng/ml (0.0 – 107.0) As troponin levels are very low; even slight elevations can indicate some degree of damage to the
TROPONIN < 0.05 ng/ml (0.0 – 0.40) heart. Increases 2 to 6 hours following an AMI, but 12 hours is required to detect elevations. If CK-
MB and myoglobin concentrations are normal but troponin levels are increased, then it is likely that
either a lesser degree of heart injury is present or that the injury took place more than 24 hours in the
past.
CK-MB is an enzyme found primarily in cardiac tissue. Elevated 4 to 6 hours after an AMI; peaks in
18 to 24 hours; returns to normal in 2 to 3 days. Myoglobin is used in conjunction with troponin and
other tests to help rule out a heart attack. Myoglobin levels start to rise within 2-3 hours of a heart
attack or other muscle injury, reach their highest levels by about 8-12 hours, and generally fall back to
normal by about one day after injury occurred.
Based on the above results, although muscle damage may be present, the damage does not appear to
be due to an AMI. EKGs show NSR with no evidence of past myocardial damage.
Sources of Information:
Dirksen, S. R., Heitkemper, M. M., and Lewis, S. M. (2004). Medical-surgical nursing: assessment and management of clinical problems (6th ed.). St. Louis: Mosby.
Dirksen, S.R., Heitkemper, M.M., and Lewis, S.M. (2004). Medical-surgical nursing: clinical companion. (3rd ed). St. Louis: Mosby.
3
1/18/2006 CBC w/5 Part Diff The Complete Blood Count (CBC) test is an automated count of the cells in the blood to provide
21:55 WBC 11.6 K/uL (4.0 – 11.0) information about WBC, RBC, and platelet populations, including the number, type, size, shape, and
RBC 2.59 M/uL (4.00 – 5.60) some of the physical characteristics of the cells.
HGB 9.4 gm/dL (12.0 – 16.0)
HCT 26.9 %VOL (41.0 – 52.0) WBC - may be increased with infections, inflammation, cancer, leukemia; decreased with some
MCV 104 l fl (82 – 96) medications, some autoimmune conditions, bone marrow failure, and congenital marrow aplasia
MCH 36.4 pg (26.0 – 36.0) WBC differential - Neutrophils, lymphocytes, basophils, eosinophils, and monocytes - are present in
MCHC 35.0 g/dL (27.0 – 35.0) relatively stable percentages that shift higher or lower depending on disease or process states.
RDW 12.1 % (9.0 – 17.0) RBC, HCT, Hgb - Decreased with anemia; increased when too many made and with fluid loss due to
PLATELETS 329 K/uL (140 – 440) diarrhea, dehydration, burns.
MPV 6.9 fl (6.0 – 10.0) MCV, MCH - increased with B12 and Folate deficiency; decreased with iron deficiency and
NEU% 73.3 % (45 – 65) thalassemia.
LYMPH% 16.6 % (24.0 – 45.0) MCHC - may be decreased when MCV is decreased; increases to amount of Hgb fits inside a RBC.
MONO% 8.5 % (1.0 – 10.0) RDW - increased RDW indicates mixed population of RBCs.
EOS% 0.8 % (0.0 – 5.0) MPV - vary with platelet production; younger platelets are larger than older ones.
BASO% 0.8 % (0.0 – 2.0)
NEU# 8.48 K/uL (2.00 – 8.00) For this patient, the increased WBCs and Neutrophils indicate a possible infectious process. The HCT
LYMPH# 1.92 K/uL (1.00 – 5.00) and remaining data may be related to pernicious anemia. Two units packet RBCs were provided to
MONO# 0.98 K/uL (0.10 – 0.90) patient on 1/19/06. Determination of pernicious anemia by physician awaiting results of ferritin, folic
EOS# 0.09 K/dl (0.00 – 0.40) acid, FE/TIBC, and B-12 which were sent to another facility for testing.
BASO# 0.09 K/dl (0.00 – 0.20)
1/18/2006 PROTHROMBIN Prothrombin Time measures vitamin K dependent clotting ability. Used to measure for clients on
21:55 PRO-TIME 12.7 SEC (10.0 – 13.0) warfarin or bleeding disorder s or disorders such as disseminated intravascular coagulation (DIC)
INR 1.10 (2.00 – 4.00)
1/18/2006 BLOOD CULTURE The Blood Culture identifies microbiologic growth in the blood. None apparent in this case.
21:55 BLOOD No Growth
RUN
1/20/2006
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1/19/2006 CMP The Complete Metabolic Panel (CMP) is a broad screening tool to evaluate organ function and check
06:14 T.BILI 0.9 mg/dL (0.0 - 1.2) for conditions such as diabetes, liver disease, and kidney disease; to monitor for known conditions
AST/SGOT 11 IU/L (5 – 34) such as hypertension; and to monitor medications for kidney and liver side effects.
ALT/SGPT 8 IU/L (0 – 43)
CALCIUM 8.0 mg/dL (8.5 – 10.6) Glucose – basic energy source for cells
ALK PHOS (R) 50 IU/L (25 – 105) Electrolytes - Ca2+; Na+; K+; Cl- - various disease states; acid base balances
CREATININE (R) 1.2 mg/dL (0.7 – 1.4) Albumin and Total Protein – various disease states; dehydration
GLUCOSE 112 mg/dL (64 -112) BUN (blood urea nitrogen) and Creatinine – state of kidneys
BUN 15.0 mg/dL (5.0 – 23.0) ALT/SGPT; AST/SGOT; Bilirubin – state of liver
T PROTEIN 5.5 gm/dL (6.0 – 8.2)
ALBUMIN 3.6 gm/dL (3.5 – 5.5)
GLOB 1.9 gm/dL (2.0 – 3.5) For this client, results are unremarkable.
NA+ 138 mmol/L (138 - 151)
K+ 4.0 mmol/L (3.7 – 5.2)
CL- 107 mmol/L (98 – 113)
CO2- 21.6 mmol/L (23.0 – 34.0)
1/18/2006 CARDIAC PANEL The Cardiac Panel tests are performed to help diagnose a client AMI.
21:55 CKMB (TRIAGE) < 1.0 ng/ml (0.0 – 4.3)
MYOGLOBIN 138.0 ng/ml (0.0 – 107.0) As troponin levels are very low; even slight elevations can indicate some degree of damage to the
TROPONIN < 0.05 ng/ml (0.0 – 0.40) heart. Increases 2 to 6 hours following an AMI, but 12 hours is required to detect elevations. If CK-
MB and myoglobin concentrations are normal but troponin levels are increased, then it is likely that
either a lesser degree of heart injury is present or that the injury took place more than 24 hours in the
past.
CK-MB is an enzyme found primarily in cardiac tissue. Elevated 4 to 6 hours after an AMI; peaks in
18 to 24 hours; returns to normal in 2 to 3 days. Myoglobin is used in conjunction with troponin and
other tests to help rule out a heart attack. Myoglobin levels start to rise within 2-3 hours of a heart
attack or other muscle injury, reach their highest levels by about 8-12 hours, and generally fall back to
normal by about one day after injury occurred.
Based on the above results, although muscle damage is apparent, the damage does not appear to be
due to an AMI
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HGB 8.3 gm/dL (12.0 – 16.0)
BASO% 0.7 % (0.0 – 2.0)
NEU# 5.11 K/uL (2.00 – 8.00) For this patient, the HCT and remaining data may be related to pernicious anemia. Two units packet
LYMPH# 0.93 K/uL (1.00 – 5.00) RBCs were provided to patient on 1/19/06.
MONO# 0.52 K/uL (0.10 – 0.90)
EOS# 0.07 K/dl (0.00 – 0.40)
BASO# 0.05 K/dl (0.00 – 0.20)
1/19/2006 RETICULOCYTES Reticulocyte Count provides an estimate of RBC production by the marrow. A corrected ret count
06:14 RETICULOCYTES 2.4 % (0.5 – 1.5) (CRC) adjust for anemia. A normal corrected retic count indicates a poor bone marrow response to
CORRECTED RETIC 1.3 % (0.5 – 1.5) peripheral anemia.
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HGB 9.9 gm/dL (12.0 – 16.0)
BASO% 0.8 % (0.0 – 2.0)
NEU# 2.29 K/uL (2.00 – 8.00) For this patient, the HCT and remaining data may be related to pernicious anemia. Two units packet
LYMPH# 0.84 K/uL (1.00 – 5.00) RBCs were provided to patient on 1/19/06. Determination of pernicious anemia by physician awaiting
MONO# 0.37 K/uL (0.10 – 0.90) results of ferritin, folic acid, FE/TIBC, and B-12 which were sent to another facility for testing.
EOS# 0.04 K/dl (0.00 – 0.40)
BASO# 0.03 K/dl (0.00 – 0.20)
1/21/2006 SPUTUM CULTURE Sputum culture used to identify microbial. Results were not available during observation. Apparent
07:00 RESULTS RESULTS problems at the laboratory.
UNAVAILABLE UNAVAILABLE
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Name Classification & Dose Times to be Reason for giving to this Nursing Implication
(Generic & trade) Action of drug ordered given patient
& route
0.9 Normal Saline Isotonic fluid IV 125 cc/hr Maintain flow, Maintain hydration, route Flow rate must be maintained as ordered, observe
change as need to for other medications for signs of dehydration or fluid overload. Check
prevent bag from IV site for patency q4 hours and whenever client
emptying is moved.
Lipitor Cholesterol Lowering 10 mg PO qAM High cholesterol Caution if liver disease.
atorvastatin
Inhibits 3 hydrocy-3- Caution if alcohol abuse.
methylglutaryl-
coenzyme A reductase
Darvocet N-100 Narcotic/NSAID 1 N-100 PO PRN Pain Mild to moderate pain relief Caution if chronic alcohol use; impaired liver or
acetaminophen/ PRN Pain kidney function.
propoxyphene napsylate Acetaminophen:
(650/100) analgesic mechanism of Caution in suicidal clients or clients with history
action unknown; of drug abuse. Caution if CNS depressant use.
antipyretic effect via Caution if impaired liver function.
direct action on the
hypothalamus heat
regulating center
Propoxyphene
napsylate: binds to
various opiate receptors
producing analgesia and
sedation (opiod agonist)
Synthroid Thyroid 0.1 mg PO qAM T4 Replacement Caution if patient experiencing acute MI.
levothyroxine qAM
Produces various Caution in adrenal insufficiency; cardiovascular
physiologic affects, disease; or if patient has DM.
including metabolism
(synthetic T4)
Rocephin 3rd Generation 1 gm IVPB q 24 hours Bacterial infection Caution if patient has penicillin allergy. Caution if
ceftriaxone Cephalosporin q24 hours patient has seizure disorder; hyperbulrubinemia;
nephrotoxic agents or impaired liver and renal
Bactericidal; inhibits function.
cell wall mucopeptide
synthesis Ensure IV patency. Ensure compatible
medications and solutions.
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Name Classification & Dose Times to be Reason for giving to this Nursing Implication
(Generic & trade) Action of drug ordered given patient
& route
Levaquin Quinolones 500 mg IVPB q 24 hours Bronchitis Caution if prolonged QT.
levofloxacin
Bactericidal; inhibits Caution in elderly patients; impaired renal
DNA gyrase and function; seizure disorder, CNS disorder;
topoisomerase IV dehydration; DM; sun exposure.
Zantac H2 Blocker 50 mg IVPB q 8 hours Nausea Caution in porphyria; impaired liver function;
ranitidine q 8 hours impaired renal function.
Selectively antagonizes
histamine H2 receptors
Ambien Anxiolytic/Hypnotic 10 mg qHS qHS Sleep aid Caution if alcohol use; drug use; depression;
zolpidem psychiatric disorder; impaired respiratory function
Interacts with GABA impaired liver function; elderly or debilitated
benzodiazepine patients.
receptor complexes
MOM Increases osmotic 30 cc PO PRN Constipation Constipation I&O ratio; check for decrease in urinary output.
magnesium hydroxide pressure, draws fluid PRN
into the colon, Constipation Identify cause of constipation; lack of fluids, bulk,
neutralizes HCl exercise.
Imdur Angianginal 30 mg PO qAM Vasodilator for peripheral Monitor pain duration, time started, activity
isoorbide mononitrate Vasodilator disease performed, character
Relaxation of vascular Monitor vitals during beginning therapy

smooth muscle which
leads to decreases in Tolerance if taken over long period
preload, after load,
which is responsible for Headache, light-headedness, decreased B/P
decreasing left
ventricular end diastolic
Phenergan Nausea/Vomiting 25 mg IV/IM q 4 to 6 hours Nausea/Vomiting Caution in pediatric patients; CNS depressant use;
phenergan q 4 to 6 hours PRN Nausea and asthma; seizure disorder; liver dysfunction;
Antagonizes central and PRN Nausea Vomiting elderly patients.
peripheral H1 receptors and Vomiting
(non-selective
antihistamine)
Skidmore-Roth, L. (2006). 2006 Mosby’s Nursing Drug Reference. St. Louis: Mosby.
9
Gordon’s Eleven Functional Health Patterns
PATTERN OF HEALTH PERCEPTION & HEALTH MANAGEMENT

 How does the person describe her/ his current health?
 What does the person do to improve or maintain her/ his health?
 What does the person know about links between lifestyle choices and health?
 How big a problem is financing health care for this person?
 Can this person report the names of current medications s/he is taking and their purpose?
 If this person has allergies, what does s/he do to prevent problems?
 What does this person know about medical problems in the family?
 Have there been any important illnesses or injuries in this person's life?
Subjective:
Client describes his health as good, and perceives her ability to continue to function at an optimal level. Does not
understand her current problem, but knows that she will improve because she “has lots to do.” Client. Client is retired and
costs of healthcare appear to not be an issue. Client and client’s spouse is aware of current medications, their purpose, and
their usage. Client is aware of allergies and avoids Cardizem, Compazine, and Gemfebrizile.
Objective:
Reason for admission: Pneumonia and chest pain. Client is alert and oriented, and is aware of current state of health. Vital
signs reflect condition and medication. B/P 132/65. PR 68. RR 16. Temp 97.8. O2 sats on RA 90%. O2 sats on 2 lpm NC
96%. Age 81. No abnormalities noted on assessment other than diminished lung sounds LLL, chest pain in same location,
and some tiredness. Client weight is appropriate for height and build. Grooming and appearance excellent. Client appears
to be suffering from pneumonia and anemia from physician’s diagnosis.
NUTRITIONAL - METABOLIC PATTERN

 Is the person well nourished?
 How do the person's food choices compare with recommended food intake?
 Does the person have any disease that affects nutritional- metabolic function?
Subjective:
Client reports that she usually has an excellent appetite but it has decreased significantly within the last couple of days.
“Nothing tastes good.” Client denies any problems eating nutritious meals at home. “I only like homemade food.”
Objective:
Client is appropriate weight for height and build. Daily weights within 2 lbs. No allergies to food. Currently experiencing
some nausea and some emesis. Emesis and BMs guaiac negative. No dental problems noted. Client does have history of
gastric ulcers but reports no problems in several years.
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PATTERN OF ELIMINATION
 Are the person's excretory functions within the normal range?
 Does the person have any disease of the digestive system, urinary system or skin?
Subjective:
Client reports no problems with bowel elimination. Denies use of any laxatives/bowel elimination aids. BMs observed
during period of observation formed and brown. Urinary elimination pattern normal, although it has increased in hospital
due to IVs. Urine observed clear, amber, no abnormal odors. Client does not identify any disease of the digestive system or
urinary system.
Objective:
Skin is warm and dry. Good peripheral pulses. Bowel sounds hypoactive in all quadrants at 20 seconds. Abdomen soft and
nontender to palpation.
PATTERN OF ACTIVITY & EXERCISE

 How does the person describe her/ his weekly pattern of activity and leisure, exercise and recreation?
 Does the person have any disease that effects her/ his cardio-respiratory system or musclo-skeletal system?
Subjective:
Client does not exercise. Activity and leisure is mostly watching grandchildren who are very active. Client provides care
for grandchildren during days parents work. Client does report some dizziness during ADLs.
Objective:
No pattern noted during hospitalization. Cardiac assessment: No JVD, capillary refill < 2 seconds. Heart sounds S1 and S2
noted. HR regular and strong. No gallops, rubs, or murmurs noted. EKG is NSR. Respiratory assessment: Minor SOB but
no cyanosis. Lung sounds diminished LLL. Normal chest rise and fall, however appears to be slightly reduced. Client is
able to perform ADLs in hospital with assistance.
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COGNITIVE - PERCEPTUAL PATTERN

 Does the person have any sensory deficits? Are they corrected?
 Can this person express her/ himself clearly and logically?
 How educated is this person?
 Does the person have any disease that effects mental or sensory functions?
 If this person has pain, describe it and it's causes.
Subjective:
Client has no sensory deficits. Client is oriented, and capable of rational and abstract thought. Client completed high
school. Client reports pain in chest in region of LLL. Pain worsens on inhalation. Client displays good long-term and
short-term memory.
Objective:
Client has history of no history of a cognitive perceptual deficit.
PATTERN OF SLEEP & REST

 Describe this person's sleep-wake cycle.
 Does this person appear physically rested and relaxed?
Subjective:
Client reports no trouble sleeping at home. Sleeps approximately 8 hours per night. During hospitalization, client reports
difficulty sleeping and believes the medication Zantac is giving her nightmares.
Objective:
Chart shows client did not sleep well, and appears tired.
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PATTERN OF SELF PERCEPTION & SELF CONCEPT

 Is there anything unusual about this person's appearance?
 Does this person seem comfortable with her/ his appearance?
 Describe this person's feeling state?
Subjective:
Client is comfortable with appearance and displays a positive attitude.
Objective:
Client displays no outward signs of stress or signs that self perception or self concept has been changed by the disease
process. Client does not have a living will or DNR/DNI in place. Client hopes to live “at least another 10 years.”
ROLE - RELATIONSHIP PATTERN

 How does this person describe her/ his various roles in life?
 Has, or does this person now have positive role models for these roles?
 Which relationships are most important to this person at present?
 Is this person currently going though any big changes in role or relationship? What are they?
Subjective:
Client understands disease process and how the disease process may change his relationships, but is unconcerned. Family
relationships are currently the most important. No changes in role relationships anticipated.
Objective:
No role changes identified.
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SEXUALITY - REPRODUCTIVE PATTERN

 Is this person satisfied with her/ his situation related to sexuality?
 How have the person's plans and experience matched regarding having children?
 Does this person have any disease/ dysfunction of the reproductive system?
Subjective:
Not discussed.
Objective:
Client does not report any disease of the reproductive system. Sexual dysfunction not discussed.
PATTERN OF COPING & STRESS TOLERANCE

 How does this person usually cope with problems?
 Do these actions help or make things worse?
 Has this person had any treatment for emotional distress?
Subjective:
Client usually handles stress well. Stress does not manifest itself into physical symptoms. Reports no use of alcohol or
drugs.
Objective:
Client displays developmental attitude of ego integrity. Emotional stress does not appear to be an issue. Very positive
attitude.
PATTERN OF VALUES & BELIEFS

 What principals did this person learn as a child that are still important to her/ him?
 Does this person identify with any cultural, ethnic, religious, regional, or other groups?
 What support systems does this person currently have?
Subjective:
Client reports that religion does play a major role in life.
Objective:
No patterns of values or beliefs were made evident during the observation period.
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Nursing Diagnosis
Date 1/21/2006 Student Name
Patient Name Medical Diagnosis Pneumonia
Pathophysiology Acute inflammation of the lung parenchyma caused by a microbial agent.
Risk Factors Reduced respiratory capacity (asthma); season; environmental conditions
Clinical Manifestation(s) Reduced respiratory capability.
Nursing Diagnosis Ineffective airway clearance related to thick secretions and consolidation as evidenced by
ineffective cough; productive cough with thick, tenacious sputum; abnormal breath sounds;
dyspnea.
Expected Outcome Client will demonstrate effective coughing and clear breath sounds; relate methods to
enhance secretion removal; and be free of cyanosis and dyspnea within 72 hours of
admission.
Nursing Interventions Evaluation/Patient Response
Auscultate breath sounds every 2 hours; monitor respiratory Client’s breath sounds auscultated every 2 hours and
patterns, including rate, depth, and effort; monitor blood gas changes documented and reported to physician; respiratory
values and pulse oxygen saturation levels and maintain effort monitored and changes documented and reported to
above 90%. physician; and oxygen saturations maintained above 90%.
Help the client to deep breathe and perform controlled Client educated to perform deep breathing and controlled
coughing. Have the client inhale deeply, hold breath for coughing. Client demonstrated completion of same.
several seconds, and cough two or three times with mouth
open while tightening the upper abdominal muscles.
Position the client to optimize respiration including head of Client positioned to optimize respiration and repositioned
bed elevated 45 degrees; shoulders relaxed; and knees every 2 hours.
flexed. Reposition at least every 2 hours.
Instruct the client and family in the importance of Client and family instructed in importance of maintaining
maintaining proper nutrition, adequate fluids, rest, and proper nutrition, adequate fluids, rest, and behavioral pacing
behavioral pacing for energy conservation and for energy conservation and rehabilitation and voiced
rehabilitation. understanding of same.
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Nursing Diagnosis Acute pain related to inflammation and ineffective home-based pain management as
evidenced by pleuretic chest pain; shallow respirations, decreased breath sounds; and
client’s report of pain.
Expected Outcome Client will report that pain management regimen relieves pain to satisfactory level with
acceptable and manageable side effects and be able to perform activities of recovery with
reported acceptable level of pain.
Determine the client's current medication use to aid in Client’s medication history was reviewed and no drug-drug
planning pain treatment; obtain a medication history help to interactions or incompatibilities was identified that would
prevent drug-drug interactions and toxicity problems that limit pain management.
can occur when incompatible drugs are combined or when
allergies are present.
Explain to the client the pain management approach that Client was provided instruction on the pain management
has been ordered, including therapies, medication approach and voiced understanding of the same.
administration, side effects, and complications
Use a preventive approach to keep pain at or below an Client was assessed and pain management provided prior
acceptable level to pain reaching an unacceptable level as identified by the
client.
Assess the client's and family's knowledge of side effects Client and client’s family were provided instruction on side
and safety precautions associated with pain medications effects and safety precautions with pain medications and
and provide education. voiced understanding of the same.
Nursing Diagnosis Activity intolerance related to interrupted sleep/wake cycle; hypoxia; and weakness as
evidenced by fatigue; unwillingness or inability to exert self; dyspnea; increased respiratory
effort; and dizziness on exertion.
Expected Outcome Client will participate in ADLs with appropriate increases in heart rate, blood pressure, and
breathing rate; verbalize an understanding of the need to gradually increase activity based
on testing, tolerance, and symptoms; and demonstrate increased activity tolerance prior to
discharge.
Determine client’s physical limitations to establish patient’s Client’s physical limitations observed and documented.
needs and capabilities. Needs and capabilities documented.
Monitor cardiorespiratory and oxygen response to activity to Obtainable goals identified and documented to ensure client
help establish obtainable goals and create appropriate can perform ADLs.
interventions.
Plan activities for periods when patient has the most energy Activities planned during midmorning and midafternoon
and alternate rest and activity periods to provide activity when client has most energy.
based on patient’s response and promote increased feeling
of accomplishment.
Encourage proper rest to reduce stress. Client encouraged to rest and take short breaks to prevent
overload and reduce stress. Client voiced understanding of
the same.
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Clinical Manifestation(s) Nausea, vomiting, confusion, shortness of breath, fatigue, and worsening angina related to
acute pernicious anemia event.
Nursing Diagnosis Ineffective therapeutic regimen management related to lack of knowledge about required
medication administration for pernicious anemia as evidenced by acute manifestations of
anemia such as nausea, vomiting, confusion, shortness of breath, fatigue, and
worsening angina; and patient’s own report of failure to continue medication because she
thought it was no longer needed.
Expected Outcome Client will verbalize acceptance and understanding of therapeutic regimen for medication
and demonstrate desire to change actions to achieve agreed-on outcomes.
Determine client’s knowledge and understanding of Client’s knowledge and understanding of pernicious anemia
condition and treatment needs to determine baseline for determined and documented.
action prior to discharge.
Assist client to develop strategies to improve management Provided information to and worked with client on disease
of anemia prior to discharge. process and methods to manage anemia including
reminders for injections and possible use of other
medications.
Emphasize to client and family need to follow therapeutic Client voiced understanding and acceptance of therapeutic
regimen agreed to in above intervention. regimen and family agreed to help client meet goals.
Mosby, Inc. items and derived items copyright 2004 by Mosby, Inc.
Discharge Planning: Based on assessment data and clinical care outcomes what do you need to do for this patient/family?
Discharge planning was performed on proper medication regime and the need for clinic follow-up to ensure medication
effective in maintaining client status. Each medication was reviewed with client and client’s spouse. Client reminded to
maintain safe home environment and minimize possible injury hazards.
17
References
Ackley, B.J. Ladwig, G.B. (2003). Nursing Diagnosis Handbook: A Guide to Planning Care, 6th Edition. St. Louis,
Missouri. C.V. Mosby.
Dirksen, S. R., Heitkemper, M. M., and Lewis, S. M. (2004). Medical-surgical nursing: assessment and management of
clinical problems (6th ed.). St. Louis: Mosby.
Dirksen, S.R., Heitkemper, M.M., and Lewis, S.M. (2004). Medical-surgical nursing: clinical companion. (3rd ed). St.
Louis: Mosby.
Ham, K.L. (2002). From LPN to RN: Role Transitions. Philadelphia. W.B. Saunders.
Jarvis, C. (2004). Physical Examination and Health Assessment. Saunders. St. Louis, Missouri.
Skidmore-Roth, L. (2006). 2006 Mosby’s Nursing Drug Reference. St. Louis: Mosby.
18

Clinical Care Concept Map - Respiratory

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Clinical Care Concept Map - Respiratory

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Idaho State University

College of Technology; Associate Degree Registered Nurse Program

Usual diagnostic labs, tests for this type of pathophysiology:

Pneumonia: - History and Physical Examination

Chest Pain: - EKG for baseline

Client/Family History that directly relates to this problem cluster:

Relaxation of vascular Monitor vitals during beginning therapy

PATTERN OF HEALTH PERCEPTION & HEALTH MANAGEMENT

NUTRITIONAL - METABOLIC PATTERN

PATTERN OF ACTIVITY & EXERCISE

COGNITIVE - PERCEPTUAL PATTERN

Client has history of no history of a cognitive perceptual deficit.

PATTERN OF SLEEP & REST

PATTERN OF SELF PERCEPTION & SELF CONCEPT

Client is comfortable with appearance and displays a positive attitude.

ROLE - RELATIONSHIP PATTERN

No role changes identified.

SEXUALITY - REPRODUCTIVE PATTERN

PATTERN OF COPING & STRESS TOLERANCE

PATTERN OF VALUES & BELIEFS

Client reports that religion does play a major role in life.

Date 1/21/2006 Student Name

Patient Name Medical Diagnosis Pneumonia

Pathophysiology Acute inflammation of the lung parenchyma caused by a microbial agent.

Risk Factors Reduced respiratory capacity (asthma); season; environmental conditions

Clinical Manifestation(s) Reduced respiratory capability.

Clinical Manifestation(s) Reduced respiratory capability.

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