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Patient Initial: Date: Patient Concept Problem: Fluid and Electrolyte Imbalance Antecedents Sufficient Cardiac Output Regulation of body fluids through Osmosis Normal Respiratory and Renal functions Assessment Data M.O 64 year old Caucasian male Admitted to the Hospital on 10/17/ Dx: Shortness of Breath, Ascites due to Alcoholic Cirrhosis HX: Hyperlipidemia, Failure to Thrive, Anemia, DVT, and coronary artery disease, HTN
3. Respiratory Distress
Interventions Priority Problem #3 Interrelated Concept: Poor Skin integrity Patient Priority Problem # Fluid Volume Excess Negative Outcomes (Complications to watch for)
1. Fluid Retention
2. Skin
Tears/Pressure
Ulcers
Teamwork and Collaboration Physical Therapist Occupational Therapist Imaging Social Worker Case Manager Respiratory Therapist Dietician Clergy Gastroenterologist Hepatologist Nephrologist Cardiology Patient Education
- Teach pt. the importance of avoiding alcohol and limiting the use of Tylenol to promote better liver function and liver toxicity 2.Teach pt. the importance of turn cough deep breathing to promote lung promotion
- Teach the patient and caregiver how to turn the patient every 1 to 2 hours to prevent further skin breakdown Priority Problem # 2 Interrelated Concept: Ineffective Gas Exchange Positive Outcomes
- Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs, and absence of edema.
- Maintain skin integrity.
- Maintain effective respiratory pattern Patient Goal
- Pt will sit on the side of the bed for at least 10- 15 minutes during the shift if to help patient go from lying to sitting 2.Turn patient every 1-2 hours to maintain skin integrity during shift.
- Pt. will demonstrate and understanding the importance of avoiding alcohol after education by the end of the shift Consequences
Patient Analysis Diagram Instructions:
1. Put the patient’s priority concept problem in the oval in the middle.
2. Add assessment data that supports the patient concept problem in the assessment data box.
Be sure to include consequences in the yellow box. Develop a patient goal that is measurable
and reflects a positive outcome.
3. Add interventions specifically for the patient priority problem in the blue box.
4. Add interrelated concepts in the green boxes. Add corresponding applicable interventions.
5. Under the interrelated concept: Patient Education, add applicable patient teaching
interventions.
6. Under the interrelated concept: Teamwork & Collaboration, add appropriate referrals.
7. Add complications to watch for in the gray boxes under negative outcomes. For each
complication add interventions. Include clinical manifestations to watch for. Add when the
HCP should be notified. Add any interventions that should be done before notifying the HCP.
8. subjective data, objective data, and diagnostic exams (including labs).
9. Add antecedents that support the patient concept problem in the antecedent’s box. Be sure to
include health history and risk factors.
10. Add the positive
Evaluation of Goal ( State whether outcome met, not met, or partially met. Explain why you think this considering the effectiveness of the nursing interventions.) Discharge Plan: Talk to patient and caregiver about noticeable swelling and pitting edema. Teach them how to press in skin to notice pitting changes For your top three-four priority nursing diagnoses on your concept map, write a short-term outcome, nursing interventions/actions, rationale for your interventions, patient responses to interventions, and evaluation of the outcome. Rationales should be written in APA format and from the assigned textbooks NOTE: PLEASE MAKE MORE COPIES IF NEEDED. EACH PROBLEM NEED INDIVIDUAL PAGE. References
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to
planning care. Elsevier.
Gaines, K. (2021, July 22). What is the Nursing Code of Ethics? Nurse.org. Retrieved October 12, 2022, from https://nurse.org/education/nursing-code-of-
ethics/
For your top three-four priority nursing diagnoses on your concept map, write a short-term outcome, nursing interventions/actions, rationale for your interventions, patient responses to interventions, and evaluation of the outcome. Rationales should be written in APA format and from the assigned textbooks NOTE: PLEASE MAKE MORE COPIES IF NEEDED. EACH PROBLEM NEED INDIVIDUAL PAGE. Key Problem: Nursing Diagnosis/Problem: Impaired Skin Integrity Short &/Or Long-Term Goal:
Maintain skin integrity free of pressure ulcers and skin tears
Nursing Interventions Rationale Patient Responses (What you did and patient reactions)
- Encourage and assist patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate. Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve and/or maintain joint mobility. 1. Pt. had a blanchable skin ulcer on the sacrum area. Pt. responded positively to the intervention
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to
planning care. Elsevier.
Gaines, K. (2021, July 22). What is the Nursing Code of Ethics? Nurse.org. Retrieved October 12, 2022, from https://nurse.org/education/nursing-code-of-
ethics/
- Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress. Use of emollient lotions and limiting use of soap for bathing may help. Edematous tissues are more prone to breakdown and to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis. 2. Patient tolerated this intervention
- Recommend elevating lower extremities. Enhances venous return and reduces edema formation in extremities. 3. Pt. tolerated this intervention positively Evaluation of Goal ( State whether outcome met, not met, or partially met. Explain why you think this considering the effectiveness of the nursing interventions.) Discharge Plan: Talk to patient and caregiver about the importance of the patient turning and rotating positions frequently to avoid further skin breakdown.
Ackley, B. J., Ladwig, G. B., Flynn, M. M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to
planning care. Elsevier.
Gaines, K. (2021, July 22). What is the Nursing Code of Ethics? Nurse.org. Retrieved October 12, 2022, from https://nurse.org/education/nursing-code-of-
ethics/
