Concept Mapping: Help me be better

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Specializes in Critical care.

Well, I guess it's my turn (again) to ask for help in here. I've been assigned my first concept map for my patient from my med surg clinicals. I need 4 nursing diagnoses, in order of priority. I think the prioritizing is the hardest part of all of this.

I kind of just wanted to put my thoughts out there to see if I'm on the right track. I remember from reading countless other posts on here that I should not be trying to fit my patient into a diagnosis, but rather look at my patient, figure out what I see and that should lead me to a diagnosis. Correct? So, I'm going to try to do that but I'm pretty new at this. Any pointers/gentle nudges (or not so gentle) would be welcomed!

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My assigned patient is a 71 yo male, admitted due to GI bleed. AO x 3, BP 96/56, HR 70, RR 16, T 98, PO2 98% room air. He denies being in pain.

His radial and pedal pulses are weak and irregular, and dysrhythmia can be heard on auscultation of atrial pulse (we haven't learned cardiac yet in med surg so I can't say specifics, ie S1, S2 yet). He is on cardiac monitoring and a call to telemetry confirmed he is in afib. His BNP is elevated, other cardiac markers in normal range. He takes both Lovenox and Coumadin at home, though since he has been in the hospital he has stopped taking these. Multiple bruises on his lower calves as well as some pitting edema (R=+1, L=+3). His PT/INR and aPTT are within range.

He is anemic. His Hgb, Hct, and RBCs are all low, in spite of receiving two units of PRBCs yesterday. He takes iron supplements and has a miralax prescription to prevent constipation. His last bowel movement was two days ago. He is asymptomatic for anemia. His skin is pink warm and dry. He moves with a steady gait, denies dizziness or shortness of breath, and his O2 sats have been consistently >95% on room air. Capillary refill

He has normal bowel sounds in all four quadrants. His first occult blood test upon admission was positive, a retest on the floor today came back negative.

He has elevated neutrophils and decreased lymphocytes.

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So based on all of this, I feel like there's a lot going on and a lot of nursing diagnoses to choose from. However, based on highest priorities, I want to look at ABCs first and what catches my attention most is his heart/blood. He has a slightly depressed BP, and inadequate RBCs, and he's in afib. Obviously his heart isn't functioning the way it should and probably not supplying adequate perfusion, so I think one of his priority nursing diagnoses should be Decreased Cardiac Output r/t atrial fibrillation and coronary artery disease AEB decreased blood pressure.

Still focusing on ABCs, his anemia and lowered RBCs would also put him at risk for inadequate oxygenation due to low RBCs, and bleeding due to his Hgb count and his use of coumadin and lovenox. His O2 sats have been fine so far, but he is at risk of inadequate oxygenation because of his decreased O2-carrying capacity... so I would add Risk for impaired gas exchange r/t anemia, and also risk for inadequate perfusion r/t anemia.

Finally, his last occult blood test was negative and they think his GI tract bleed cleared up on its own, but they aren't sure. I think any bleeding, especially with his risk factors, is pretty serious for him so I would put Risk for Bleeding r/t anticoagulants and history of GI bleeds.

so in order my diagnoses:

Decreased Cardiac Output r/t atrial fibrillation and coronary artery disease AEB decreased blood pressure

Risk for impaired gas exchange r/t anemia

risk for inadequate perfusion r/t anemia

Risk for Bleeding r/t anticoagulants and history of GI bleeds

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Now, can you help me be better? Thanks for making it through my whopper of a post!

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Specializes in Critical care.

PS- sorry for any spelling or obvious errors, it is late and I am fuzzy-brained. I will check again in the morning!

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....oh good you'll see this in the morning...

check out this thread. dymyertifies it

Concept Mapping

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
admitted due to GI bleed. AO x 3, BP 96/56, HR 70, RR 16, T 98, PO2 98% room air.

He is on cardiac monitoring and a call to telemetry confirmed he is in afib.

His BNP is elevated

takes both Lovenox and Coumadin

Multiple bruises on his lower calves as well as some pitting edema (R=+1, L=+3)

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis. Another member GrnTea say this best......
A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Decreased Cardiac Output: according to NANDA decreased cardiac output is.....Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body.

The defining characteristics are....

Altered Heart Rate/Rhythm

Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload

Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload

Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility

Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional

Anxiety; restlessness

Related Factors (r/t)

Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

So looking at this how would you restate your ND #1

Decreased Cardiac Output r/t atrial fibrillation and coronary artery disease AEB decreased blood pressure

So what proof do you have of this? The patient is hypotensive AEB BP 96/56....did you do orthostatic vitals? The hypotension might be due to the AFib...however you have a low H/H (what exactly were the hemoglobin and hematocrit?). The patient was admitted with GI bleed which might mean this is a volume issue as well. The patient is also in AFib. The loss of atrial kick can decrease the cardiac output due to the loss of the atrial kick.

So you have Decreased Cardiac Output r/t ....altered preload and altered cardiac rhythm AEB a fib AEB hypotension low H/H, GI bleed the monitor showing AFib, an elevated BNP, and hypotension

You also have a volume issue IF the H/H is low enough. Deficient fluid volume...Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level

Defining Characteristics

Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

Related Factors (r/t)

Active fluid volume loss; failure of regulatory mechanisms

So how would you make you ND statement?

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Risk for impaired gas exchange r/t anemia

risk for inadequate perfusion r/t anemia

Risk for Bleeding r/t anticoagulants and history of GI bleeds

Now...what resource are you using for your NANDA? does it have a NANDA risk for inadequate perfusion r/t anemia or is it....Risk for decreased Cardiac tissue perfusion. They also have Constipation....and they are at Risk for Shock due to the GI bleed.
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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

Concept Mapping Homepage

How to construct a concept map.

http://faculty.ucc.edu/nursing-villanueva/Med-Surg%20Concept%20Map%20example.pdf

Concept Mapping

These are really helpful links.....you can also purchase care map software.

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Specializes in Critical care.
He is on cardiac monitoring and a call to telemetry confirmed he is in afib.

His BNP is elevated

takes both Lovenox and Coumadin

Multiple bruises on his lower calves as well as some pitting edema (R=+1, L=+3)

Decreased Cardiac Output: according to NANDA decreased cardiac output is.....Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body.

The defining characteristics are....

Altered Heart Rate/Rhythm

Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload

Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload

Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility

Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional

Anxiety; restlessness

Related Factors (r/t)

Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

So looking at this how would you restate your ND #1

UMMMMMMmmmm.... decreased cardiac output r/t altered heart rhythm, altered preload, and altered afterload, AEB afib, edema, and decreased peripheral pulses?

You also have a volume issue IF the H/H is low enough. Deficient fluid volume...Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium level.

Defining Characteristics

Change in mental state; decreased blood pressure, pulse pressure and pulse volume; decreased skin and tongue turgor; decreased urine output; decreased venous filling; dry mucous membranes; dry skin; elevated hematocrit; increased body temperature; increased pulse rate; increased urine concentration; sudden weight loss (except in third spacing); thirst; weakness

Related Factors (r/t)

Active fluid volume loss; failure of regulatory mechanisms

So how would you make you ND statement?

Hgb-9.9 after 2 units blood. (it was 7.3 before). Hct- 29.9 after blood.

I don't know that I have enough evidence for the fluid volume loss. Besides the decreased blood pressure and skin turgor, he doesn't have the other factors such as dryness of skin and membranes, weight loss, etc.

Now...what resource are you using for your NANDA? does it have a NANDA risk for inadequate perfusion r/t anemia or is it....Risk for decreased Cardiac tissue perfusion. They also have Constipation....and they are at Risk for Shock due to the GI bleed.

I knew he was risk for constipation, but didn't know if that would count as a priority diagnosis. Wouldn't ABC issues such as cardiac output and inadequate gas exchange come first? Not trying to be argumentative, by the way, just trying to understand. :)

My nursing care plan resource guide SUCKS but I am at the library right now looking at some other books. None of them are the NANDA, which I know i need to get.

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Specializes in Critical care.

Thank you! I am bookmarking all of those!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

decreased cardiac output r/t altered heart rhythm, altered preload, and altered afterload, AEB afib, edema, and decreased peripheral pulses?

Decreased Cardiac Output r/t ....altered preload and altered cardiac rhythm AEB a fib AEB hypotension low H/H, GI bleed the monitor showing AFib, an elevated BNP, and hypotension. Don't forget the BNP which indicates heart failure which is pump failure and diminished cardiac output.

I don't know that I have enough evidence for the fluid volume loss. Besides the decreased blood pressure and skin turgor, he doesn't have the other factors such as dryness of skin and membranes, weight loss, etc. Hgb-9.9 after 2 units blood. (it was 7.3 before). Hct- 29.9 after blood.

You are on the right track..... however the patient is still hypotensive and you have a diminished circulation volume as indicated by the low H/H even if it is improved it is still symptomatically low. I would consider it a priority. He doesn't need them all he needs one that applies.

I knew he was risk for constipation, but didn't know if that would count as a priority diagnosis. Wouldn't ABC issues such as cardiac output and inadequate gas exchange come first? Not trying to be argumentative, by the way, just trying to understand.

Not a priority but you need four of them. Did they ever locate the source of his bleeding?

The patient was on both Lovenox and Coumadin at home? Are his coags still elevated...yes he is still a risk for re-bleeding.

He is also at risk for shock due to the GI bleed and compromised cardiac output if he bleeds again.

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

My nursing care plan resource guide SUCKS but I am at the library right now looking at some other books. None of them are the NANDA, which I know i need to get.

amazon rents the NANDA book it is the source for ND. I use Ackley...Nursing Diagnosis Handbook: An Evidence-Based Guide To Planning Care, 9e or http://www.amazon.com/Nursing-Diagnosis-Handbook-Evidence-Based-Planning/dp/0323085490/ref=sr_1_1?ie=UTF8&qid=1412018017&sr=8-1&keywords=ackley+nursing+diagnosis

The NANDA resource book Nursing Diagnoses 2012-14: Definitions and Classification: 9780470654828: Medicine & Health Science Books @ Amazon.com the new version is becoming available in October.

Amazon has free shipping for students

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Specializes in Critical care.
decreased cardiac output r/t altered heart rhythm, altered preload, and altered afterload, AEB afib, edema, and decreased peripheral pulses?

Decreased Cardiac Output r/t ....altered preload and altered cardiac rhythm AEB a fib AEB hypotension low H/H, GI bleed the monitor showing AFib, an elevated BNP, and hypotension. Don't forget the BNP which indicates heart failure which is pump failure and diminished cardiac output.

I don't know that I have enough evidence for the fluid volume loss. Besides the decreased blood pressure and skin turgor, he doesn't have the other factors such as dryness of skin and membranes, weight loss, etc. Hgb-9.9 after 2 units blood. (it was 7.3 before). Hct- 29.9 after blood.

You are on the right track..... however the patient is still hypotensive and you have a diminished circulation volume as indicated by the low H/H even if it is improved it is still symptomatically low. I would consider it a priority. He doesn't need them all he needs one that applies.

I knew he was risk for constipation, but didn't know if that would count as a priority diagnosis. Wouldn't ABC issues such as cardiac output and inadequate gas exchange come first? Not trying to be argumentative, by the way, just trying to understand.

Not a priority but you need four of them. Did they ever locate the source of his bleeding?

The patient was on both Lovenox and Coumadin at home? Are his coags still elevated...yes he is still a risk for re-bleeding.

He is also at risk for shock due to the GI bleed and compromised cardiac output if he bleeds again.

Thank you, as always, for your wonderful help and for the time you put into helping other students as well as myself.

They never did locate the source of bleeding.

I think part of my problem, confusion-wise (and not to place blame, but this is part of why this feels so hard) is that I don't have all the information needed to do this. I only have part of it. We haven't really covered cardiac, I had no idea what a BUN was until I saw my patient's and went and looked it up... there's just a lot of pieces missing still. I'll get there, I know, but sometimes it's hard to know what I don't know if that makes sense.

Anyways, thanks!

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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.

I have attached to my sig line a critical thinking flow sheet fr students....it was made by a dear member Daytonite...open it it will help

You also need a good NANDA resource....I use Ackley and the bible....NANDA Nursing Diagnoses 2012-14: Definitions and Classification by NANDA International.

I have been where you are and I remember it vividly! LOL It will eventually make sense....((HUGS))

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