Rasmussen College Concept Map Nursing Diagnosis: Short Term Goal ✓ Solved

Develop a concept map that includes the following components: Nursing Diagnosis: Short Term Goal: Long Term Goal: Clinical Manifestations: Subjective: Objective: Evaluation of Plan or Anticipated Evaluation of Plan: Nursing Interventions (at least 4): Collaboration: With whom will the nurse be working and why? Patient’s Laboratory & Test Results: Patient’s Past Medical History and Significant Findings: Patient’s Medical Diagnosis Pulmonary Embolism.

Paper For Above Instructions

The nursing diagnosis of pulmonary embolism (PE) is a critical clinical issue that requires focused intervention and comprehensive care planning. This concept map will guide healthcare professionals in managing patients diagnosed with PE by outlining necessary short-term and long-term goals, clinical manifestations, nursing interventions, and essential collaborations.

Nursing Diagnosis

The primary nursing diagnosis for a patient experiencing a pulmonary embolism is impaired gas exchange related to decreased perfusion of the lung tissue and resultant hypoxemia. This diagnosis stems from the blockage of pulmonary arteries, often due to thromboembolic events.

Short Term Goals

The short-term goal for a patient with pulmonary embolism is to maintain adequate oxygen saturation levels above 90% within 24 hours. This will be monitored via pulse oximetry, and appropriate supplemental oxygen will be provided as necessary. Additional short-term goals include the patient's ability to verbalize understanding of the intervention strategies to prevent further embolic events and to report any changes in their condition during their hospital stay.

Long Term Goals

The long-term goal is to promote the patient's return to baseline respiratory function and prevent recurrence of pulmonary embolism within six months of discharge. This includes educating the patient on lifestyle changes, such as smoking cessation, regular mobility exercises, and adhering to anticoagulant therapy as prescribed, to help mitigate risk factors for future thromboembolic events.

Clinical Manifestations

Subjective Manifestations

Subjective symptoms reported by the patient may include sudden onset of shortness of breath, chest pain, and a feeling of impending doom. Patients may describe pain is worse with deep breathing or coughing, reflecting pleuritic nature of some of the chest pain.

Objective Manifestations

Objective findings may include tachypnea (rapid breathing), tachycardia (increased heart rate), decreased breath sounds, and abnormal lung auscultation, which can show crackles in areas affected by perfusion deficits. Diagnostic tests can reveal decreased oxygen saturation levels, abnormal arterial blood gases (ABG), and imaging studies such as a CT scan of the chest indicating the presence of clots in pulmonary arteries.

Evaluation of Plan or Anticipated Evaluation of Plan

The evaluation of the plan will involve continuous monitoring of the patient’s vital signs, particularly respiratory rate and oxygen levels, alongside regular assessments through arterial blood gases to gauge the effectiveness of interventions. The nursing team should also engage in regular discussions with the patient regarding their understanding of the disease process and adherence to the prescribed care plan.

Nursing Interventions

Key nursing interventions to manage a patient with pulmonary embolism include:

  • Administration of anticoagulant medications as prescribed, including monitoring the patient for any signs of bleeding or adverse reactions.

  • Implementation of oxygen therapy to maintain adequate oxygen saturation levels and prevent hypoxia.

  • Regular monitoring of vital signs, particularly respiratory status, and providing interventions as needed for any changes in the patient's condition.

  • Providing education to the patient and their family on pulmonary embolism, its risk factors, preventive measures, and the importance of medication adherence.

Collaboration

The nurse will collaborate with a multidisciplinary team comprising respiratory therapists, pharmacists, physicians, and dietitians. Collaboration with respiratory therapists is essential in managing the patient's airway and optimizing respiratory function. The pharmacist will play a critical role in monitoring the anticoagulant therapy and ensuring there are no drug interactions. Coordinating with the physician is vital for adjusting medical therapies based on patient response and progress. Lastly, dietary considerations can help manage patient comorbidities, which may affect overall recovery.

Patient’s Laboratory & Test Results

Laboratory results for a patient with pulmonary embolism may include elevated D-dimer levels, which suggest the presence of thrombus formation. Imaging studies, such as a CT pulmonary angiogram, will typically confirm the diagnosis by displaying obstructive clots within the pulmonary arteries. Additionally, arterial blood gases may show hypoxemia and a respiratory alkalosis due to hyperventilation.

Patient’s Past Medical History and Significant Findings

A significant past medical history may include previous venous thromboembolism (VTE), malignancies, immobilization, or recent surgeries. Such conditions predispose patients to the development of clots, which can lead to pulmonary embolism.

Patient’s Medical Diagnosis

In this case, the medical diagnosis is pulmonary embolism, characterized by sudden onset of symptoms and confirmed by imaging studies and laboratory findings. The management of this diagnosis requires an intricate understanding of pathophysiology, therapeutic protocols, and post-discharge considerations to reduce recurrence risk.

Conclusion

In conclusion, the development of a comprehensive concept map addressing nursing diagnosis, goals, clinical manifestations, interventions, and collaboration is essential in managing patients with pulmonary embolism. Through careful monitoring, timely interventions, and patient education, nurses can significantly impact patient outcomes and promote recovery.

References

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