NURS 2410 Concept Mapping

#1 Nursing Diagnosis:Impaired gas exchange Supportive Data:R/T decreased pulmonary perfusionAEB c/o SOB with any exertion, pain with deep breathing, decreased O2 saturation with ambulation. | #2 Nursing Diagnosis:Risk for bleedingSupportive Data:R/T anticoagulation therapy; Heparin drip infusing @ 13.7 mL/hr |

Admitting Diagnosis/ Problem:Chest pain, back painPriority Assessments:Vital signs, telemetry, peripheral pulses, respiratory status, monitor for signs and symptoms of bleeding, pain assessment, restlessness, irritability, confusion, somnolence, tachypnea, dyspnea, significant decrease in oximetry results, decreased PaO2 and/or increased PaCO2, central cyanosis |

#3 Nursing Diagnosis:Impaired physical mobility Supportive Data:R/T left lower extremity clot and right lower extremity edema and pain AEB c/o pain with ambulation and ROM of lower extremities |

Relationship of Diagnoses BRIEFLY explain the relationship (causative or resultant) between your selected nursing diagnoses. If the diagnoses are unrelated, state that. The impaired gas exchange and impaired physical mobility are directly related to the patient’s diagnosis of DVT and PE. The risk for bleeding is correlated because of the heparin drip needed for the treatment of PE and DVT. |

Priority Nursing Diagnosis: Goal, Outcomes, Interventions and Responses

Priority Nursing Diagnosis Impaired gas exchange r/t decreased pulmonary perfusion aeb c/o SOB with any exertion, pain with deep breathing, and decreased O2 saturation with ambulation.

Expected Outcomes (measurable)

INTERVENTIONS | CLIENT RESPONSE TO INTERVENTIONS | INSTRUCTOR FEEDBACK | 1.) Maintain client on bed rest to reduce oxygen demands during acute respiratory distress; increase activity gradually as allowed and tolerated2.) Maintain oxygen therapy as ordered3.) Perform actions to