NIGHTINGALE COLLEGE
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
Name: Denny Lee
Cours BSN-246
e:
Client Information (SBAR) Concept of the
Map
Jane Doe is an 82 year old female who is exhibiting the following Perfusion
symptoms - acute respiratory distress, chest pain, fever, and extreme
fatigue, with signs of impaired systemic perfusion. Her vital signs are
Situation tachycardia (HR 130), hypotension (BP 100/52), tachypnea (RR 28),
fever (101.3 F), and oxygen saturation of 92% on room air. She appears
pale, anxious, and unable to lie down flat, and needs to remain in a
tripod position to breathe.
The patient has a history of COPD, hypertension, obesity, and long-term
smoking, which all increases her risk for oxygen delivery and
cardiovascular strain. She reports one week of poor oral intake,
Background
insomnia, fever, and productive cough with blood-tinged sputum. She
lives alone and has limited support, both increasing her risk for delayed
care and dehydration.
Pulmonary: crackles auscultated in bilateral upper and middle lobes
with diminished lower lobe sounds leads to impaired ventilation
resulting in V/Q mismatch and reduced O2 delivery.
Cardiovascular: sinus tachycardia and borderline hypotension leads to
compensatory response to maintain cardiac output and perfusion
pressure
Assessment
Neurologic: Anxiety, inability to concentrate, headache leads to possible
decreased cerebral perfusion and hypoxia.
Renal: Dark, concentrated urine leads to decreased renal perfusion
likely related to dehydration and low circulating volume.
Skin/General: Pallor and fatigue leads to reduced systemic oxygen
delivery.
Recommendation Recommend immediate interventions to support and restore perfusion,
including:
- Initiate supplemental oxygen and continuous pulse oximetry.
Begin IV fluid resuscitation to improve circulating volume and
blood pressure.
- Obtain chest imaging and labs (CBC, CMP, lactate, blood
, cultures) to evaluate infection severity and perfusion status.
- Start broad-spectrum antibiotics promptly per pneumonia/sepsis
guidelines.
- Closely monitor urine output, mental status, vital signs, and
lactate as markers of perfusion.
Recognize Cues Analyze Cues
Vitals were provided in the situation report. Pulmonary/Oxygen delivery: shortness of
breath and tachypnea (RR 28), O2 Sat at 92%
Px reports chest pain, shortness of breath, headache, on room air, crackles in bilateral middle and
and extreme fatigue. Suffering from chills, difficulty upper lobes; diminished lower lobe sounds
sleeping, poor appetite, and coughs. States she is
unable to lie flat and anxiety prevents her from Cardiovascular: HR (130 bpm) and BP (100/52)
concentration and breathing properly. can indicate the body trying to maintain
perfusion pressure
Infection: fever temp at 101.3 F and chills
Prioritize Hypotheses Generate Solutions
Impaired Tissue Perfusion (systemic and The patient will maintain adequate tissue
pulmonary) due to impaired O2 delivery, infection perfusion by intervention via oxygen
1. and vital signs 1. therapy, IV fluids, and infection treatment
all within 12 hours of receiving treatment.
Monitor vitals as well. (Statpearls, 2025).
Impaired Gas Exchange due to alveolar The patient will demonstrate improved
inflammation, V/Q mismatch, and COPD gas exchange (oxygenation and
ventilation). Bring oxygen saturation
2.
levels above 94% and RR below 24, along
with improving auscultation and clear lung
2. sounds (Cicvarić, 2024).
The patient will achieve adequate
hydration and increase fluid volume via IV
3.
fluids and oral intake as tolerated. Monitor
BP, HR and urine outputs. (Santos, 2024).
Decreased Fluid Volume due to poor oral The patient will demonstrate calm
intake, fever, and fluid loss behavior and decrease anxiety with
3. 4.
nursing interventions for breathing and
patient education.
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
Name: Denny Lee
Cours BSN-246
e:
Client Information (SBAR) Concept of the
Map
Jane Doe is an 82 year old female who is exhibiting the following Perfusion
symptoms - acute respiratory distress, chest pain, fever, and extreme
fatigue, with signs of impaired systemic perfusion. Her vital signs are
Situation tachycardia (HR 130), hypotension (BP 100/52), tachypnea (RR 28),
fever (101.3 F), and oxygen saturation of 92% on room air. She appears
pale, anxious, and unable to lie down flat, and needs to remain in a
tripod position to breathe.
The patient has a history of COPD, hypertension, obesity, and long-term
smoking, which all increases her risk for oxygen delivery and
cardiovascular strain. She reports one week of poor oral intake,
Background
insomnia, fever, and productive cough with blood-tinged sputum. She
lives alone and has limited support, both increasing her risk for delayed
care and dehydration.
Pulmonary: crackles auscultated in bilateral upper and middle lobes
with diminished lower lobe sounds leads to impaired ventilation
resulting in V/Q mismatch and reduced O2 delivery.
Cardiovascular: sinus tachycardia and borderline hypotension leads to
compensatory response to maintain cardiac output and perfusion
pressure
Assessment
Neurologic: Anxiety, inability to concentrate, headache leads to possible
decreased cerebral perfusion and hypoxia.
Renal: Dark, concentrated urine leads to decreased renal perfusion
likely related to dehydration and low circulating volume.
Skin/General: Pallor and fatigue leads to reduced systemic oxygen
delivery.
Recommendation Recommend immediate interventions to support and restore perfusion,
including:
- Initiate supplemental oxygen and continuous pulse oximetry.
Begin IV fluid resuscitation to improve circulating volume and
blood pressure.
- Obtain chest imaging and labs (CBC, CMP, lactate, blood
, cultures) to evaluate infection severity and perfusion status.
- Start broad-spectrum antibiotics promptly per pneumonia/sepsis
guidelines.
- Closely monitor urine output, mental status, vital signs, and
lactate as markers of perfusion.
Recognize Cues Analyze Cues
Vitals were provided in the situation report. Pulmonary/Oxygen delivery: shortness of
breath and tachypnea (RR 28), O2 Sat at 92%
Px reports chest pain, shortness of breath, headache, on room air, crackles in bilateral middle and
and extreme fatigue. Suffering from chills, difficulty upper lobes; diminished lower lobe sounds
sleeping, poor appetite, and coughs. States she is
unable to lie flat and anxiety prevents her from Cardiovascular: HR (130 bpm) and BP (100/52)
concentration and breathing properly. can indicate the body trying to maintain
perfusion pressure
Infection: fever temp at 101.3 F and chills
Prioritize Hypotheses Generate Solutions
Impaired Tissue Perfusion (systemic and The patient will maintain adequate tissue
pulmonary) due to impaired O2 delivery, infection perfusion by intervention via oxygen
1. and vital signs 1. therapy, IV fluids, and infection treatment
all within 12 hours of receiving treatment.
Monitor vitals as well. (Statpearls, 2025).
Impaired Gas Exchange due to alveolar The patient will demonstrate improved
inflammation, V/Q mismatch, and COPD gas exchange (oxygenation and
ventilation). Bring oxygen saturation
2.
levels above 94% and RR below 24, along
with improving auscultation and clear lung
2. sounds (Cicvarić, 2024).
The patient will achieve adequate
hydration and increase fluid volume via IV
3.
fluids and oral intake as tolerated. Monitor
BP, HR and urine outputs. (Santos, 2024).
Decreased Fluid Volume due to poor oral The patient will demonstrate calm
intake, fever, and fluid loss behavior and decrease anxiety with
3. 4.
nursing interventions for breathing and
patient education.
