This nursing concept map addresses care for a 62-year-old female admitted following cardiac arrest and subsequent anoxic brain injury. The patient collapsed at a dialysis facility after refusing treatment and was resuscitated with CPR, AED shocks, and epinephrine. The map is organized around three priority nursing concepts: airway and breathing, circulation and hemodynamic stability, and neurological status. For each concept, the map outlines system-specific assessments, nursing interventions, expected outcome criteria, relevant medications, and supporting laboratory data. Evaluation findings indicate that airway and circulatory outcomes were met, while neurological outcomes were only partially achieved due to fluctuating consciousness and motor function.
Client: 62-year-old female | Weight: 105 kg | Allergies: Morphine, Percocet
Reason for Admission: Cardiac arrest with subsequent anoxic brain injury.
Pertinent History and Information: The patient refused her last dialysis treatment and collapsed at the dialysis facility. She received CPR and AED shocks on site and was given epinephrine en route to the hospital. She has received all COVID-19 vaccines and is currently on Zofran, Plavix, and Trazodone.
Three priority nursing concepts guide this care plan:
Corresponding overall outcomes are as follows: the patient will maintain a patent airway and adequate oxygenation; the patient will demonstrate stable hemodynamics and adequate tissue perfusion; and the patient will maintain the highest possible level of consciousness and neurological function.
System-Specific Assessment:
Nursing Interventions:
System-Specific Assessment:
Nursing Interventions:
System-Specific Assessment:
Nursing Interventions:
Medication Related to This Concept: Zofran (ondansetron) — administered for nausea prevention, which can affect breathing comfort.
Labs for This Outcome: Arterial blood gases (ABGs), complete blood count (CBC).
Medication Related to This Concept: Plavix (clopidogrel) — as part of antiplatelet therapy.
Labs for This Outcome: Troponin levels; electrolytes (potassium, sodium, calcium); coagulation profile (if on anticoagulant).
Medication Related to This Concept: Trazodone — consider holding if the patient is not fully conscious.
Labs for This Outcome: Serum glucose; serum ammonia (if liver function is a concern); complete metabolic panel.
Arterial Blood Gases (ABGs): Results indicated adequate oxygenation with current oxygen therapy. pH 7.35, PaCO2 45 mmHg, PaO2 80 mmHg, HCO3⁻ 24 mEq/L. These values suggest adequate ventilation and oxygenation at current therapy settings. Nursing indication: Assess the patient's respiratory status and oxygenation continuously; use ABG trends to guide ventilator or oxygen therapy adjustments.
"ABG, troponin, and CBC results with nursing implications"
"Shift outcomes evaluated; clinical judgment for each concept"
"IV pump precautions and dialysis adherence teaching"
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