- 2- Concept Map on one a respiratory diagnosis and one perfusion condition/diagnosis
- 2 Medication Templates that relate to each diagnosis (which is a total of 4)
- 2 NANDA-approved nursing diagnoses (one for each diagnosis) ie Alteration in Metabolism r/t, AEB subjective and objective data, Nursing Intervention, Outcome, Evaluation
Concept Map: Respiratory Diagnosis – Chronic Obstructive Pulmonary Disease (COPD)
Concept Map: Perfusion Diagnosis – Deep Vein Thrombosis (DVT)
Medication Templates:
- Respiratory Diagnosis (COPD) Medication Template:
- Medication: Bronchodilators (e.g., Albuterol)
- Route: Inhalation (Metered-Dose Inhaler)
- Dosage: 2 puffs every 4-6 hours
- Indication: To relieve bronchoconstriction and improve airflow in COPD patients.
- Potential Side Effects: Tachycardia, Tremors, Dry Mouth
- Precautions: Caution in patients with cardiac arrhythmias or hypertension.
- Nursing Considerations: Monitor heart rate and blood pressure. Instruct the patient on proper inhalation technique.
- Perfusion Diagnosis (DVT) Medication Template:
- Medication: Anticoagulant (e.g., Heparin)
- Route: Subcutaneous injection
- Dosage: 5000 IU every 12 hours
- Indication: To prevent further clot formation and facilitate dissolution of existing clots in DVT patients.
- Potential Side Effects: Bleeding, Thrombocytopenia
- Precautions: Use with caution in patients at risk of bleeding or with a history of heparin-induced thrombocytopenia.
- Nursing Considerations: Monitor for signs of bleeding, assess platelet count, and ensure proper subcutaneous injection technique.
NANDA-Approved Nursing Diagnoses:
- Alteration in Gas Exchange r/t Impaired Respiratory Function (COPD)
- AEB Subjective Data: Shortness of breath, cough, increased sputum production, fatigue.
- AEB Objective Data: Use of accessory muscles, decreased breath sounds, oxygen saturation <90%, increased respiratory rate.
- Nursing Intervention:
- Administer prescribed bronchodilators as per schedule to improve airflow.
- Encourage and assist the patient in performing deep breathing exercises.
- Monitor oxygen saturation and respiratory rate regularly.
- Educate the patient about energy conservation techniques.
- Outcome: The patient will demonstrate improved oxygenation and decreased shortness of breath.
- Evaluation: The patient’s oxygen saturation remains within the target range, and they report decreased breathlessness during activities.
- Impaired Tissue Perfusion r/t Blood Clot Formation (DVT)
- AEB Subjective Data: Swelling, pain, warmth, and tenderness in the affected leg.
- AEB Objective Data: Visible swelling and redness in the leg, positive Homan’s sign, increased calf circumference.
- Nursing Intervention:
- Administer prescribed anticoagulants to prevent clot progression.
- Elevate the affected leg to reduce swelling and improve blood flow.
- Apply warm compresses to the affected area to relieve pain.
- Instruct the patient on the importance of avoiding prolonged immobility.
- Outcome: The patient will maintain adequate tissue perfusion and have reduced pain and swelling.
- Evaluation: The patient’s calf circumference decreases, and they report a decrease in pain and tenderness in the affected leg.