Nursing Concept Map for NURS 412/422

Client Age and Gender: 62 F Weight: 105 kg Height/Length: n/a Allergies: morphine, percocet

Reason for Admission: Cardiac arrest with subsequent anoxic brain injury

Pertinent History/Information: Refused last dialysis treatment, collapsed at dialysis facility, received CPR and AED shocks, given epinephrine en route, has had all COVID vaccines, on Zofran, Plavix, Trazodone

Priority Concept #1: Airway/Breathing

Priority Concept #2: Circulation/Hemodynamic Stability

Priority Concept #3: Neurological Status

Outcome: Patient will maintain a patent airway and adequate oxygenation

Patient will demonstrate stable hemodynamics and adequate tissue perfusion

Patient will maintain the highest possible level of consciousness and neurological function

System Specific Assessment:

1. Respiratory rate and pattern

2. Oxygen saturation levels

3. Breath sounds

4. Presence of any respiratory distress

System Specific Assessment:

1. Blood pressure

2. Heart rate and rhythm

3. Capillary refill

4. Peripheral pulses

System Specific Assessment:

1. Glasgow Coma Scale (GCS)

2. Pupil size and reactivity

3. Motor and sensory function

4. Level of consciousness

Interventions: The nurse will

1. Monitor respiratory status every 2 hours

2. Administer supplemental oxygen as ordered

3. Position patient to optimize ventilation

4. Prepare for emergency intubation if indicated

Interventions: The nurse will

1. Monitor vital signs every hour

2. Administer IV fluids as ordered

3. Administer vasoactive medications as ordered

4. Assess for bleeding due to anticoagulation therap

Interventions: The nurse will.

1. Perform neurological checks every 2 hours

2. Maintain elevated to decrease intracranial pressure

3. Administer sedation as ordered to prevent agitation

4. Protect patient from injury due to altered mental status

Outcome Criteria: The patient will.

1. Demonstrate normal resp rate limits

2. Maintain oxygen saturation >94%

3. Exhibit clear breath sounds bilaterally

4. Show no signs of respiratory distress

Outcome Criteria:...

Maintain blood pressure within parameters

2. Have heart rate between 60-100 bpm

3. Exhibit capillary refill of less than 2 seconds

4. Have strong and equal peripheral pulses

Outcome Criteria: The patient will.

1. Maintain GCS score as per baseline or improve

2. Have pupils equal, round, and reactive to light

3. Retain or regain baseline motor and sensory function

4. Exhibit no unexplained decrease in level of consciousness

Medications R/T Concept Above:

Zofran (for nausea prevention which can affect breathing comfort)

Medications R/T Concept Above:

Plavix (as part of the antiplatelet therapy)

Medications R/T Concept Above:

Trazodone (consider holding if patient is not fully conscious)

Labs for Above Outcome:

Arterial blood gases (ABGs), Complete blood count (CBC)

Labs for Above Outcome:

Troponin levels

Electrolytes (Potassium, Sodium, Calcium)

Coagulation profile (if on...

…assessments and consider additional diagnostic tests to evaluate the cause of fluctuations in consciousness.

Priority Lab/Procedures Results/Interpretations Nursing Indications (Pre & Post)

Arterial Blood Gases (ABGs) - Results indicated adequate oxygenation with current oxygen therapy. Assess the patient's respiratory status and oxygenation . pH 7.35, PaCO2 45 mmHg, PaO2 80 mmHg, HCO3- 24 mEq/L: These results suggest adequate ventilation and oxygenation at the current oxygen therapy settings.

Troponin Levels - Results were within normal limits, no indication of myocardial injury. Evaluate the patient for any signs of chest pain or discomfort. Troponin I <0.04 ng/mL: This result is within normal limits, indicating no new myocardial injury.

Complete Blood Count (CBC) - Results showed slight anemia, which will need to be monitored. Check for any history of bleeding disorders or anticoagulant use. Hemoglobin 10 g/dL, Hematocrit 30%, WBC 12,000/uL: Indicative of mild anemia and a possible mild leukocytosis

Equipment / Risks/ Precautions: Intravenous infusion pumps - Monitor for infiltration and ensure proper functioning to deliver medications and fluids.

Patient/Family Support and Teaching: Educate on the importance of adherence to dialysis treatment to prevent future cardiac events. Discuss the…