Concept Map Care Plan N360
Impaired Swallowing
Pureed diet, thickened honey
liquids
Evaluated by speech therapist
Hx CVA, Dementia
Non-verbal
Limited awareness
Impaired Physical Mobility
Contracted bilateral legs with
slight movement
Hx of CVA- right sided
weakness
Reposition q2h
ROM
Impaired Tissue Integrity
Impaired mobility
Rt heel pressure ulcer
Excoriated buttocks
Scratching buttocks
Inzo cream to buttocks
Safegel to heel
Daily dressing change for heel
Karissa Higa
Risk for Unstable BG Level
BG 200s-300s- hyperglycemia
BG 31- hypoglycemia
Diabetes II
Regular Insulin Sliding Scale
D50 1 amp prn
Chief Medical Diagnosis:
Asthma
Priority Assessments:
Breathing Pattern, Lung
Sounds, O2 Sat., LOC., BG
checks, VS, Wound
Assessment, sign of hypo or
hyperglycemia, temperature.
Hypothermia
Temp. 35 C
Hypoglycemic
Warm to touch
Added blanket and
towel to keep warm
Ineffective Breathing Pattern
Wheezing
Hx COPD
Advair
Prednisone
Ineffective Airway Clearance
Wheezing
Coughing
Hx COPD
Advair
Prednisone
Concept Map Care Plan N360
Desired Outcomes
Ineffective Breathing Pattern
 The patient will maintain
an effective breathing
pattern, as evidenced by
relaxed breathing at
normal rate and depth
and absence of dyspnea.
Karissa Higa
Interventions
Ineffective Breathing Pattern
 Assess respiratory rate, rhythm, and depth.
 Monitor breathing patterns.
 Assess breathing position
 Monitor for changes in LOC and VS
 Assess skin color and temperature
 Use pulse oximetry to evaluate O2 saturation.
 Encourage pt to clear his own secretions with effective coughing.
 Administer prescribed medications.
 Teach caregivers appropriate breathing, coughing, and splinting techniques.
 Educate pt and caregivers about prescribed medications.
 Explain use of oxygen therapy, including type and se of equipment and why its maintenance is
important.
Ineffective Airway Clearance
Ineffective Airway Clearance
 Patient will maintain clear
 Assess airway patency
open airways as
 Auscultate lungs after coughing for presence of adventitious breath sounds.
evidenced by normal
 Assess respirations, not quality, rate, rhythm, depth, flaring of nostrils, dyspnea on exertion,
breath sounds, normal
evidence of splinting, use of accessory muscles, and position for breathing.
rate and depth of
 Assess changes in LOC
respirations, and ability to
 Assess changes in HR, BP, and temperature.
effectively cough up
 Assess cough for effectiveness and productivity.
secretions after
 Assess secretions, noting color, viscosity, odor, and amount.
treatments and deep
 Use pulse oximetry to monitor oxygen saturation; assess ABGs.
breaths.
 Assist in pt. performing coughing and breathing maneuvers.
 Use upright position
 If cough ineffective, use nasotracheal suctioning as needed.
 Administer medications as ordered noting effectiveness and side effects.
 Instruct caregivers regarding need for humidification and adequate hydration
 Instruct caregivers on prescribed medications and coughing techniques.
Concept Map Care Plan N360
Risk for Unstable BG Level
 Pt maintains BG within
defined target ranges.
Hypothermia
 Pt maintains body
temperature above 35°C.
Impaired Mobility
 Patient is free of
complications of
immobility, as evidenced
by intact skin, absence of
thrombophlebitis, normal
bowel pattern, and clear
breath sounds.
Impaired Tissue Integrity
 Pt’s tissues return to
Karissa Higa
Risk for Unstable BG Level
 Assess for signs of hyperglycemia and hypoglycemia
 Monitor BG as ordered (before every meal and HS)
 Assess pattern of physical activity
 Educate pt/caregiver on medications, insulin administration, signs and symptoms of
hyperglycemia and hypoglycemia
Hypothermia
 Monitor temperature
 Assess heart rate, rhythm, BP, O2 sat
 Determine precipitating factor/event
 Monitor labs
 Apply extra blankets to keep pt warm
 Bear hug order
 Explain all procedures and treatments
Impaired Mobility
 Assess for impediments to mobility
 Assess ability to perform ROM to all joints
 Monitor nutritional status
 Evaluate need for assistive devices and home assistance
 Assess skin integrity
 Assess elimination status
 Allow pt to perform takss at his own rate, do not rush pt
 Provide positive reinforcement
 Institute measures to prevent skin breakdown
 Reposition q2h
 Encourage CDB
 Instruct caregiver on hazards of immobility
 Educate caregivers on safe home environment, exercises (ROM), nutrition importance, and
medications.
Impaired Tissue Integrity
 Assess condition of tissue
Concept Map Care Plan N360
normal structure and
function.
Impaired Swallowing
 Patient exhibits ability to
safely swallow, as
evidenced by absence of
aspiration, no evidence of
coughing or choking
during eating/drinking,
no stasis of food in oral
cavity after eating, and
ability to ingest
foods/fluid.
Karissa Higa
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Assess characteristics of wound, including color, size, drainage, and odor
Assess VS for elevated fever
Identify signs of itching and scratching
Provide skin care as needed
Administer antibiotics as ordered
Encourage diet that meets nutritional needs (protein to promote wound healing)
Teach pt or caregiver about proper wound care, signs and symptoms of infection, and when to
notify PCP
Assess for presence of gag and cough reflexes
Assess strength of facial muscles
Assess coughing or choking during eating and drinking
Assess ability to swallow small amount of water
Assess for residual in food in mouth after eating
Assess results of swallowing studies as ordered
Maintain high fowlers position with head flexed
Provide small frequent meals
Encourage pt to chew thoroughly, eat slowly, and swallow frequently, especially if extra slaiva
is produced.
Proceed slowly, giving small amounts; whenever possible, alternate servings of liquied and
solids
Place whole or crushed pills in custard or gelatin
Demonstrate to the pt, caregiver, or family what should be done if pt aspirates
Encourage family members to seek out CPR instruction
Evaluation:
For ineffective breathing pattern I determined if the outcome was met by evaluating the pts breathing pattern, O2 sat,
respiratory status and LOC. After these assessments the pt had an O2 sat of 99% on room air, respiratory rate of 20
breaths/min, unlabored breathing and no use of accessory muscles. Pt was disoriented x3 related to his hx of dementia.
Overall, pts breathing pattern was acceptable and showed no signs of respiratory distress, and outcome was met.
For ineffective airway clearance I evaluated the pts respiratory status, once again, plus assessed his cough effectiveness
and productivity to calculate if the outcome was met. After my assessments pt couldn't cough when told but when he did his
Concept Map Care Plan N360
Karissa Higa
lungs were clear after auscultation. Initially in the morning the pt had wheezing on expiratory but after medication
administration his lungs were clear. Overall, pts outcome was partially met as evidenced by normal respiratory rate and depth,
but unable to cough up secretions after treatments and deep breaths.
Risk for unstable BG was monitored by glucose checks before every meal and at nighttime. Unfortunately, my pts
glucose levels fluctuated constantly. Usually by dinnertime his glucose was in the high 300s to low 400s so according to the
sliding scale more insulin was needed. However, by the time the glucose reading came in for the morning he had dropped to 31
and was now hypoglycemic. Once the nurses saw that value D50 1 amp was given and pt glucose went back up after 30min. I
continued to monitor him throughout the day and pt remained asymptomatic when his glucose increased to 180 at lunch.
Insulin was given at lunch and pt ate 100% of his meal. Overall, pt remained comfortable in bed by the end of my shift but the
goal was not met.
This week my pt also suffered from hypothermia with a temperature of 34C-35C. After assessments I reported the
abnormal to my nurse and we discussed about ordering a bear hug, but it didn't not happen. Instead I put extra blankets on the
pt and put a towel over his head and neck to try and warm him up. I was constantly taking temperature every 30min to make
sure his temperature was going up. By the end of my shift his temperature had risen to 35.7C so the outcome was eventually
met.
My pt was also immobile and stayed in bed the whole time. His legs were contracted with some movement and he had
right sided weakness due to a hx of CVA. He was a total assist pt so I made sure to reposition him q2h, check his briefs for
incontinence, and kept his skin clean and dry. Patient’s goal was partially met due to the pressure ulcer on his heal and
excoriated buttocks.
For impaired skin integrity my pt had a right heel pressure ulcer and excoriated buttocks. I applied barrier cream to his
buttocks and changed the heel dressing. I assessed the wound at the heel and it looked like it was healing well. However, pt
goal was not met due to the healing wound and excoriation to the buttocks.
For impaired swallowing my pts goal was met and he did not aspirate while I fed him. He was great at chewing his food
and I made sure to feed him slowly. After I was sure he swallowed all his food I gave him another spoonful of food. I also
alternated food and liquids to prevent food from being left in the mouth. Lastly, I crushed the pts medications and mixed it
with thickened juice to prevent aspiration.
Discharge Plan/ Patient Teaching:
1. Placement: Home
2. Support systems: family- daughter and family, wife
3. Assistance needed w/ ADLs: Feeding, oral care, bathing, PROM, turn q2h, peri care, all done by family.
Concept Map Care Plan N360
Karissa Higa
4. Equipment needs: Safegel, Keflix, and Telfa for wound care on heel, nebulizer for updraft treatments as needed,
thickener for feeding (nectar consistency diet for dysphagia), syringes for insulin administration, barrier cream for
buttocks (Inzo), briefs and chux.
5. Patient teaching:
a. How pt learns: Educate caregivers, pt disoriented x3
b. Barriers: Primary language Filipino, non verbal most of the time
c. Topics to be addressed: Medications, wound care, reposition q2h, when to call PCP, how to prevent asthma
attacks, insulin administration, body temperature regulation, PROM exercises, home safety (prevent falls, skin
breakdown, clutter free, etc), finances if applicable, resources for emotional support, educate on caregiver strain
and how to prevent it, home care agencies to help relieve family members, insurance to decrease cost of
medications and supplies.