Cedar Crest College

Physiological Stressor # 1 Physiological Stressor # 2 Madison

S Student Concept Map, p1 S
My heart feels like butterflies Its hard to swallow chewy foods. This Pleasants
Life threatening stressors cheese is too tough.
RR 20, coughing, +2 edema, BP 117/62, 04/13/2016
penetrate Core
PT 18, Hematocrit 47.8%, Digoxin
Esophageal stricture, depressed cough
O 125m, hx hypertension, Metoprolol Abnormal Symptoms penetrate O
normal line of defense reflex, lack of oral hygiene, dysphagia,
tartrate 25mg, Warfarin sodium 2mg
dentures
Stressors penetrate flexible line of
Decreased cardiac output r/t altered defense & ^risk for penetration of NLD Risk for aspiration r/t esophageal stricture
A contractility aeb increased HR, coughing, A and depressed cough reflex aeb bedside
edema and increased BP. swallow study and dysphagia.

P Patients cardiac status will remain stable. P Patient wont exhibit signs of aspiration
Medical Diagnosis:
Nausea/vomiting
CC:Nausea/vomitin
g
Positive Variable
Positive Variable Aiding Resistance
Aiding Defense Integrity vs
Despair Sits upright when
Lives with daughter, eating, elevates
maintains diet, walks leg with edema,
often inflammation
HPI: esophageal response
stricture, A Fib,
diastolic CHF

Other Stressor # 4
Physiological Stressor # 3 S I cry everyday when I think of my husband
S
aaaaI feel so full after only eating two bites! but hes been passed for some time now.
Vomiting, diarrhea, inadequate nutrient Anxiety, RR 20, HR 96, BP 117/62,
intake, false feelings of feeling full, loss of 4 O verbalized inability to cope, fatigue,
Flexible line of defense
O lbs in one week, hx GERD, Loperamide Gabapentin 100mg, mild dementia,
HCL 2mg PRN Lorazepam 1mg
Normal line of defense
Ineffective coping r/t situational crisis
Imbalanced nutrition: less than body A aeb decreased use of social support,
A requirements r/t weight loss of 4 lbs/week Lines of Resistance fatigue, and maladaptive coping
aeb diarrhea, vomiting, and inability to behavior.
ingest enough nutrients Basic Structure/Central
Core P Patient will be verbalizing an increased
P Patient will eat more than half of every meal coping mechanism.
without vomit or diarrhea following.

Student Name: Madison Pleasants
Nursing Dx # : Decreased cardiac output r/t altered contractility aeb increased HR, coughing, edema and increased BP.
Behavioral Outcome: The client will have controlled hypertension, reduced edema, and decreased HR on the day of care.
Nursing Interventions: Independent,
Dependent & Collaborative (all need
to directly relate to meeting
outcomes/ goals)
Measure and record intake and
output accurately. Independent
Teach patient about reportable
symptoms, prescribed diet,
medications, and activity level.
Collaborative
Monitor and record LOC, heart rate
and rhythm, and blood pressure at
least every 4 hours. Independent
Nurse will administer anti-
hypertensive, anti-arrhythmic, and
anti-coagulation medicine
appropriately as prescribed.
Dependent
Provide skin care every 4 hours.
Independent
Cedar Crest College - Nursing Concept Map (page 2)
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Scientific Rationale for Selected
Interventions
Decreased urine output without
lowered fluid intake might indicate
pulmonary congestion and
diminished cardiac output (Sparks
& Taylor, 2014, p.49).
These measures let patient and
caregivers participate in patients
care and help patient make informed
decisions about health status
(Sparks & Taylor, 2014, p.52).
To detect cerebral hypoxia
possibly resulting form decreased
cardiac output (Sparks & Taylor,
2014, p.49).
To reduce or eliminate
arrhythmias (Sparks & Taylor,
2014, p.52).
To enhance skin perfusion and
venous flow (Sparks & Taylor,
2014, p.49).
Implementation Phase (Indicate
what you, the nurse, the therapist,
etc did on the day of care)
Assisted CNA and dietitian in
accurately measuring and
recording dietary intake. SN
assisted in output measuring and
recording.
Taught patient about symptoms of
heart problems, prescribed diet,
medications, and activity level.
patient understood the need for a continued
Assessed LOC, heart rate and
rhythm and blood pressure every
4 hours.
The nurse accurately administered
the daily medication.
Assisted in providing skin care
every 4 hours.
Evaluation Phase/Client Response to care
(Note specific and measurable data you
collected after the intervention to give
evidence if your planned interventions
helped the client)
Client ate 25% of a cheese omelet as the
cheese posed as a hazard. Client ate 75% of
her lunch that included cup fruit, 2oz cup
of apple juice, 12oz cup of water, mashed
potatoes and meatloaf.
SN couldnt measure urine output
accurately due to patient privacy; patient
made 2 BMs.
Patient stated she already knew the
symptoms of heart arrhythmias, reasoning
behind the prescribed diet and medications.
After teaching the patient active ROM,
activity level.
0800 Alert and oriented x4, HR 96,
arrhythmic normal S1/S2 present, BP
113/63. 1200 Alert and oriented x4, HR 88,
arrhythmic normal S1/S2 present, BP
118/66.
The patients blood pressure remained
stable, and the heart arrhythmias were very
mild. No coagulation problems were noted
on the day of care.
0800 Assisted patient in a bed bath.
1200 Provided patient with a light
therapeutic massage with moisturized
lotion.
Outcomes met? Why or Why not? Explain. SN was unable to accurately measure and record the patients intake and output. Patient teachings, assessments, and
skin care were performed by SN with expected outcomes met. The nurse on duty administered the anti-hypertensive, anti-arrhythmic, and anti-coagulation
medicine appropriately as prescribed. Outcomes were partially met.

Cedar Crest College - Nursing Concept Map (page 3)

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Student Name: Madison Pleasants
Nursing Dx # : Risk for aspiration r/t esophageal stricture and depressed cough reflex aeb bedside swallow study and dyspnea.

Behavioral Outcome: The client will effectively swallow all foods, liquids, and medications on the day of care.

Nursing Interventions: Independent,
Dependent & Collaborative (all need
to directly relate to meeting
outcomes/ goals)
Elevate the head of the bed or place
patient in the Fowlers position.
Independent
Scientific Rationale for Selected
Interventions
To aid breathing (Sparks & Taylor,
2014, p. 402).
Implementation Phase (Indicate
what you, the nurse, the therapist,
etc did on the day of care)
The head of the patients bed
remained elevated or in the
Fowlers position.
Evaluation Phase/Client Response to care
(Note specific and measurable data you
collected after the intervention to give
evidence if your planned interventions
helped the client)
Patient stated that the elevation of the head
of the bed did assist in her breathing.

Change the patients position at least To reduce the potential for Patient was ambulated at least Secretions and blood were able to drain
every 2 hours. Independent aspiration by allowing secretions every two hours by SN. properly due to ambulation. Patient state, I
and blood to drain (Sparks & feel great walking around.
Taylor, 2014, p.403)
Encourage fluids within prescribed Fluids and humidification liquefy Patient was encouraged to drink The patient did not struggle with coughing
restrictions. Independent secretions (Sparks & Taylor, 2014, the 4oz of juice that was given up any secretions that arisen.
p. 402). with both meals and her 16oz
water cup was re-filled 3 times by
SN.
Assess the patient for gag and Impaired reflexes may cause On admission the patient wasPatient was on a soft-mechanical diet due to
swallowing reflexes. aspiration (Sparks & Taylor, 2014, assessed for gag and swallowing impaired cough reflex.
Dependent p. 402). reflexed.
Recognize the progression of airway To detect complications early The patient did not present with
Patient was monitored and did not aspirate.
compromise and report your (Sparks & Taylor, 2014, p. 402). any progression of airway
findings. compromise as noted by SN.
Collaborative
Outcomes met? Why or Why not? Explain. The head of the bed remained elevated or in the Fowlers position, the patient was ambulated to change position, fluids
were encouraged to liquefy secretions, on admission a swallow/gag reflex assess was performed, and the SN monitored the progression of any airway compromise.
The outcomes were fully met.

Cedar Crest College - Nursing Concept Map (page 4)

 Attach Clinical prep sheet to this form
Student Name: Madison Pleasants
Nursing Dx # : Imbalanced nutrition: less than body requirements r/t weight loss of 4 lbs/week aeb diarrhea, vomiting, and inability to ingest enough nutrients.

Behavioral Outcome: The client will eat > 50% of all meals and >8 glasses of water without vomiting or diarrhea following on the day of care.

Nursing Interventions: Independent,
Dependent & Collaborative (all need
to directly relate to meeting
outcomes/ goals)
Obtain and record patients weight at
the same time every day.
Independent
Scientific Rationale for Selected
Interventions
To obtain accurate readings
(Sparks & Taylor, 2014, p. 218).
Implementation Phase (Indicate
what you, the nurse, the therapist,
etc did on the day of care)
Assisted is obtaining daily weight.
Evaluation Phase/Client Response to care
(Note specific and measurable data you
collected after the intervention to give
evidence if your planned interventions
helped the client)
Patient is weighted at 0800 each day. The
patient has shown a loss of 4lbs in one
week.

Provide a diet that meets the patients A diet meeting (the patients) Encouraged patient to eat as much Patient was able to eat 25% of the breakfast
daily caloric requirement. caloric requirement helps meet (the food that was provided as that was provided and 75% of the lunch.
Collaborative patients) maintenance and growth possible. When eating breakfast the patient stated,
needs (Sparks & Taylor, 2014, Its hard to swallow chewy foods. This
p.440). cheese is too tough. SN unsuccessfully
attempted to get patient a new meal.
Monitor fluid intake and output. Body weight may decrease as a Assisted CNA and dietitian in Client ate 25% of a cheese omelet as the
Independent result of fluid loss (Sparks & accurately measuring and cheese posed as a hazard. Client ate 75% of
Taylor, 2014, p.218). recording dietary intake. SN her lunch that included cup fruit, 2oz cup
assisted in output measuring and of apple juice, 12oz cup of water, mashed
recording. potatoes and meatloaf.
SN couldnt measure urine output
accurately due to patient privacy; patient
made 2 BMs.
Provide oral hygiene. To help keep patient comfortable Assisted the patient in providing 0800 the patient was given a bed bath in
Independent (Sparks & Taylor, 2014, p.219). oral hygiene. which the SN performed oral care that
included denture and gum cleaning.
Monitor bowel sounds once per shift. Normal active bowel sounds may Auscultated bowel sounds. 0800 the patient presented with active bowel
Independent indicate readiness for enteral sounds.
feedings; hyperactive sounds may
indicate poor absorption and may be
accompanied by diarrhea (Sparks &
Taylor, 2014, p.218).
Outcomes met? Why or Why not? Explain. SN was unable to accurately measure and record the patients intake and output. Patient was weighed at the beginning
of the shift. Patient was encouraged to eat as much food as possible but SN was unable to get the patient a new meal when the cheese was too chewy due to the
patient being uncooperative. At 0800 the patient was given a bed bath in which oral care was provided and the SN auscultated active bowel sounds. Outcomes
were partially met.
 Cedar Crest College - Nursing Concept Map (page 5)
Attach Clinical prep sheet to this form
Student Name: Madison Pleasants
Nursing Dx # : Ineffective coping r/t situational crisis aeb decreased use of social support, death of husband, fatigue, and maladaptive coping behavior.

Behavioral Outcome: The client will identify and demonstrate ability to use at least two healthy coping behaviors on the day of care (Sparks & Taylor,
2014, p.91).

Nursing Interventions: Independent,
Dependent & Collaborative (all need
to directly relate to meeting
outcomes/ goals)
Arrange to spend uninterrupted
periods of time with patient.
Encourage expression of feelings,
and accept what patient says.
Independent
Scientific Rationale for Selected
Interventions
Devoting time to
listening helps patient express
emotions, grasp situation, and cope
effectively (Sparks & Taylor, 2014,
p.91).
Implementation Phase (Indicate
what you, the nurse, the therapist,
etc did on the day of care)
Provided the patient with
uninterrupted time throughout the
entire day.
Evaluation Phase/Client Response to care
(Note specific and measurable data you
collected after the intervention to give
evidence if your planned interventions
helped the client)
Patient stated, Youre an angel sent from
heaven. Im so happy you spent the day
with me.

Identify and reduce unnecessary Avoid subjecting patient to sensory Provided the patient with a quiet, Patient enjoyed the view of the city, dim
stimuli in environment. or perceptual overload (Sparks & calm room with the blinds open lights and the quiet room.
Independent Taylor, 2014, p.91). but the lights dim.

Teach patient relaxation techniques Relaxation can assist to reduce Taught the patient relaxation Patient was able to quickly regain a calm
of deep breathing and guided anxiety and feelings of anger techniques of deep breathing and demeaned after an emotion breakdown. The
imagery. Independent (Sparks & Taylor, 2014, p.91). guided imagery. deep breathing and guided imagery assisted.

Request feedback from patient about Encourage patient to evaluate Patient stated, The breathing really helped
Ask the patient for feedback about
behaviors that seem to work. effect of these behaviors (Sparks & deep breathing and guided and I kept reminiscing about our wedding
Independent Taylor, 2014, p.91). imagery. day.
Explain all treatments and To allay fear and allow patient to Explained all activities with
Patient enjoyed ambulating, the moisturized
procedures and answer patients regain sense of control (Sparks & patient before preforming them lotion, and being taught active ROM. SN
questions. Taylor, 2014, p.91). and answered all of the patients
answered the patients questions regarding
Collaborative questions regarding care. the skin cream that was prescribed for a
mild rash.
Outcomes met? Why or Why not? Explain. The patient was given uninterrupted time throughout the entire day, and was given a quiet room that reduced all
unnecessary stimuli. The patient was taught, and the used and provided feedback for relaxation techniques of deep breathing and guided imagery. The patient was
included in all activity decisions and all questions were answered. The outcomes were fully met.