Concept Map Care plans and Nursing Dx help

  1. Hey everyone!

    I am a new ADN student working on my FIRST care plan and boy did I have a great patient for it..

    The patient is a 61 y/o male who presented to the ER with complaints of CP, SOB and diaphoresis. MI was r/o and he was found to have Acalculous Cholecystitis. After having a cholecystectomy (and other numerous procedures) he had to have an ERCP to place a stint in his common bile duct. He has other medical dx of DM II, CAD s/p PCTA, anemia, HTN, and Renal Insuff. His BP was extremely elevated (208/48 at one point), BUN and Creatinine elevated, GFR of 34, and abnormal ABG's.

    I have came up with the 3 most important dx in his case, I believe but wanted to get some other input.

    ** Decreased Cardiac output
    ** Impaired Gas Exchange
    ** Excess Fluid Volume

    I am also having difficulty with my "r/t" and "AEB" on each of these.. Any help will be greatly appreciated and any other clinical info will gladly be given to you in order to help me!

  2. Visit MagickalSpiral profile page

    About MagickalSpiral

    Joined: Oct '07; Posts: 14; Likes: 2
    from US


  3. by   Daytonite
    hi, magickalspiral, and welcome to allnurses!

    as i always do when a student is asking for help with a care plan i start, as you should as well, by going through the steps of the nursing process which are:
    1. assessment (collect data)
    2. nursing diagnosis/patient problem (group your abnormal assessment data, and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
    3. planning (write measurable goals/outcomes and nursing interventions)
    4. implementation (initiate the care plan)
    5. evaluation (determine if goals/outcomes have been met)
    step #1 - assessment: you've already provided me some of the assessment information, but i still have some questions about it:
    • cp (chest pain)
    • sob (shortness of breath)
    • diaphoresis
    • bp was extremely elevated (208/48 at one point)
    • bun and creatinine elevated (what were the actual values?)
    • gfr of 34
    • abnormal abg's (what were the actual values?)
    what you must understand about the nursing process and writing a care plan is that this abnormal assessment information is what forms the entire foundation of everything else that follows in your care plan. and, i mean everything. these abnormal data items are your patient's signs and symptoms that you are going take action on. you use them to determine your nursing diagnoses in step #2 and your goals and nursing interventions in step #3 of the nursing process.

    as a cross check in determining if your assessment was thorough and worth any salt you also look at all the information you gleaned from the patient's medical record. this patient has other medical problems:
    • type ii diabetes
    • coronary artery disease with a history of a ptca (percutaneous transluminal coronary angioplasty)
    • hypertension
    • renal insufficiency
    • a cholecystectomy for cholecystitis
    • an ercp to place a stint in his common bile duct
    you need to go to some references on these medical conditions to look up the common signs and symptoms of them to see if your patient had any of them that you might have missed when you did your assessment. this is part of your learning experience. when we are new to nursing and assessment we tend to overlook important signs and symptoms of various diseases and this is how you learn to correct yourself. i bring this up because no where in your post do you mention anything about this patient's blood sugars or diabetic medication/control, the treatment he is receiving for his atherosclerosis of his coronary artery disease, what is being done about his chest pain, what is being done about his post-op cholecystectomy pain, what is being done about his diet, or what is being done about his surgical incisions since this man has had two surgical interventions!

    step #2 - nursing diagnoses/determination of the patient's problems: during this part of the nursing process or care planning process you take your list of signs and symptoms (nanda calls them defining characteristics) and you pull out your nursing diagnosis reference book and you start looking for nursing diagnoses that have symptoms that match with those that your patient has. this is the way medical students learn to diagnose medical diseases as well. each medical disease has a list of signs and symptoms; each nursing diagnosis also has a list of defining characteristics (signs and symptoms) that you now have from your assessment activity. the reason you are having problems with your "aeb" items on your nursing diagnoses is probably because they aren't the proper defining characteristics that fit that particular nursing diagnosis. you would only know this by looking at the reference information for each particular nursing diagnosis. i'll take you through one to show you what i'm talking about.

    nursing diagnosis: impaired gas exchange

    definition: excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane.

    defining characteristics (signs and symptoms): abnormal arterial blood gases, abnormal arterial ph, abnormal breathing (e.g., rate, rhythm, depth), abnormal skin color (e.g., pale, dusky), confusion, cyanosis (in neonates only), decreased carbon dioxide, diaphoresis, dyspnea, headache upon awakening, hypercapnia, hypercarbia, hypoxemia, hypoxia, irritability, nasal flaring, restlessness, somnolence, tachycardia, visual disturbances.
    [does you patient have any of these symptoms?]

    related factors (etiology behind the problem or the signs and symptoms): alveolar-capillary membrane changes, ventilation perfusion imbalance

    (page 94, nanda-i nursing diagnoses: definitions & classification 2007-2008 published by nanda international). this information can also be found at [color=#3366ff]impaired gas exchange and

    i've highlighted in red and bolded three defining characteristics (symptoms) your patient has that classifies him to this nursing diagnosis. these are his "aeb" items for your 3-part nursing diagnostic statement. his "r/t" item is what the etiology, or cause, for his oxygen deficiency is. you have two choices according to the reference. do you know what each choice is? look them up if you have to. the alveolar-capillary membrane has to do with the ability of gases to pass through the pulmonary alveolar-capillary membrane. are there physical changes in the membrane causing an inhibition of the gases to be exchanged? you would only know this by knowing the underlying pathophysiology of the patient's disease processes. ventilation perfusion imbalance has to do with balance of oxygen and carbon dioxide that are passing through the alveolar-capillary membrane--it should basically be what is going to give you normal blood gasses readings of oxygen and carbon dioxide. in people with conditions like lung problems you are going to find gas exchange problems due to the lung membranes being clogged with secretions that inhibit gas exchange so an alveolar-capillary membrane problem exists. your patient is sob because of his cardiac condition where the perfusion of oxygen at the cellular level is being compromised, not because of anything wrong at the lung membranes. so, your nursing diagnostic statement for this patient should be as follows:
    impaired gas exchange r/t ventilation perfusion imbalance aeb abnormal arterial blood gases [you really should state the blood gas results exactly as they were or use the medical terms for them: hypercapnia, hypercarbia, elevated ph, etc.], diaphoresis, and shortness of breath
    step #3 - planning: now! your goals and nursing interventions are aimed at:
    • the abnormal arterial blood gasses (ex: giving oxygen)
    • treating the patient's diaphoresis (ex: supplying clean linens)
    • treating the patient's shortness of breath (ex: teaching positioning for comfort)
    your overall goal(s) being to eradicate or normalize any of the above and normalize or eliminate the main problem of "excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane" which, recall, is the definition of the nursing diagnosis.

    can you see the logic to all of this? it forms a nice closed circle. when you put this into the form of a concept map it is all going to relate and make a lot more sense. this is why some schools have gone to using concept mapping.

    now, i think you have a little more work to do with this care plan because i think you've left out a few important things. i would be looking at some wound healing or wound care and some dietary things since this guy just had his gut altered and he is a diabetic. he can't be eating a lot of high fat foods. so, he needs some teaching about this. take a good look at all the medications he is on and relate them to his medical diseases to help you with the pathophysiology of what is going on with him before picking a nursing diagnosis. the decreased cardiac output is probably a valid one to use for his cad and hypertension, but you need to know the related factors and get his signs and symptoms of it clear. how far has his heart failure gone? heart failure proceeds in a step by step fashion. you didn't mention it, but does he have any peripheral edema? and, what's going on with his diabetes? it's likely that his hypertension and atherosclerosis are related to the diabetes as these are common complications of diabetes.

    if you are still having trouble with this care plan, post more questions.
  4. by   Daytonite
    oops! i forget to tell you that there is information on concept mapping on this sticky thread:
  5. by   MagickalSpiral

    Thanks for your help. I am aware that there is a lot of information that I omitted in that last post, I was trying to get some of the most important things out there first.

    For our concept map we only have to pick the 3 top dx to elaborate on, but I have a list of about 10 that I feel are relevant to this patient. The top three are the ones that I am discussing here.

    Some other information on this patient is below..
    He is a diabetic as mentioned before and his sugars have been very much elevated ranging from 110 to 382, generally staying in the 200's. He is on SSI for this as well as NPH. He states that at home his DM is controlled. In regards to his ABG's (he's had 2 sets), the pH has ranged from 7.30 to 7.32, and the Base Excess from -5.9 to -2.9. His BUN has ranged from 32 - 98 and his creatinine from 2.0 to 5.6. During his long stay (15 days so far) he has had 2 CXR's showing bibasal atelectasis and cardiomegaly; 2 different Central Line placements; a VQ scan ruling out Pulmonary Emoblism (elevated D-Dimer of 1166); CT of Thorax (no abmormal findings); Emergency Dialysis (for Stage IV renal disease); bilateral pitting edema of lower extremities (to knees). He is on Morphine and Percocet for his post op pain. He experiences a good bit of nausea and is on Zofran and Phenergan to control those sxs. He is on numerous BP meds, some only when the SBP is elevated above 150. He takes Lasix to help with the edema and was also on a Nitrodrip for the CP which has since ceased. He does have Nitrostat at bedside to use prn. He is anemic with a Hemoglobin ranging from 9.3 to 12.6, hematocrit from 28.8 to 38, Iron 15-35 and Ferritin from 172.8 to a whopping 1879.3. He also had a BNP of 7.1 at admission that increased to 150.8 several days later. He is on a Renal/Anti-reflux diet, 2000 calories 2 gm Na, 40 gm protein, 2 g K, with one can of supplena daily.

    Hope this information is enough to get a little more input on my other 2 dx.

    Thanks for all of your help, this first care plan is a doozy!
  6. by   Daytonite
    use the symptoms as aeb items to support the use of the nursing diagnoses you've chosen. as i said, use a nursing diagnosis book to verify you have classified all your symptoms correctly. then, you need to sequence your three diagnoses in an order of priority. maslow is how i prioritize them, but your instructors might have given you another way to prioritize.'s_hierarchy_of_needs
    by maslow, i would place your diagnoses in this order:
    1. impaired gas exchange
    2. decreased cardiac output
    3. excess fluid volume