NIGHTINGALE COLLEGE
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
NURSING PROCESS TEMPLATE: Concept- Perfusion
Assessment (Recognizing Cues) Evelyn Harris is a 76-year-old female admitted to the
medical-surgical unit with complaints of increased
Which client information is relevant? What client data is most
fatigue, dizziness when standing, and swelling in her
important? Which client information is of immediate concern?
ankles. Her daughter reports that she has been "more
Consider signs and symptoms, lab work, client statements, H &
P, and others. Consider subjective and objective data. tired than usual" over the past few days and “can’t walk
as far without needing to sit down.”
Medical Hx: Congestive heart failure (CHF), hypertension
(HTN), hyperlipidemia (HLD), and coronary artery disease
(CAD). She had a stent placed two years ago
Subjective Data:
"more tired than usual"
“can’t walk as far without needing to sit down.”
Objective Data:
VS: Temp 98.7F, 108HR, RR20, 88/54, pain 0/10,
O2 Sat 92%RA
Pale, cool skin on extremities
Bilateral (BL) +2 pitting edema in ankles
Capillary refill > 3 seconds
Jugular vein distention noted when sitting upright
Lung sounds: crackles at bases bilaterally
Labs: Hemoglobin 10.2g/dL, Hematocrit 31%,
BNP 640pg/mL, Troponin normal range, Sodium
132mEq/L, Creatinine 1.5mg/dL
Immediate Concern:
Hypotension indicating signs of decreased cardiac
output
O2 Sat 92%RA with presence of crackles indicate
potential pulmonary congestion
BNP level elevated indicating possible worsening
heart failure
Low hemoglobin and hematocrit which can
impair oxygen delivery to the tissues in the body
Elevated creatinine which may indicate
decreased renal perfusion
Client conditions that are consistent with the cues:
Analysis (Analyzing Cues)
The cues all strongly suggest the patient is experiencing
Which client conditions are consistent with the cues? Do the cues
decreased cardiac output and possible congestive heart
support a particular client condition? What cues are a cause for
concern? What other information would help to establish the
failure (CHF).
significance of a cue?
Client conditions that are consistent with the cues:
Elevated BNP is a biomarker indicating ventricular
stretch and fluid overload which is commonly
seen in heart failure
Hypotension and tachycardia are signs the heart
is not pumping effectively
Pulmonary crackles and low O2 saturation
Page 1 of 13
, suggest fluid backing up into the lungs
Peripheral edema and jugular vein distention
indicate fluid retention and increased venous
pressure.
Fatigue and dizziness suggest there is reduced
tissue oxygenation due to poor perfusion.
What cues are a cause for concern:
Hypotension with blood pressure of 88/54mmHg
can reduce organ perfusion and lead to further
complications.
Tachycardia with heart rate of 108 bpm may be a
compensatory response but also increases the
cardiac workload.
Crackles in lungs and O2 sat of 92%RA indicate
pulmonary congestion and risk of respiratory
compromise.
BNP level confirms significant cardiac strain.
Increased creatinine levels may indicate
decreased renal perfusion and early kidney
involvement.
Pale, cool skin and delayed capillary refill show
peripheral circulation is compromised.
What other information would help to establish the
significance of a cue?
Echocardiogram results would provide
information regarding the ejection fraction and
overall heart function.
Intake and output records help assess fluid
balance and influence diuretic management.
Vital signs trends and weight could confirm
worsening or improvement of heart failure
symptoms.
Medication adherence history to determine if
worsening symptoms might be due to missed
doses or ineffective therapy.
Electrolyte panel and liver function tests to assess
for other organ involvement due to reduced
perfusion
What explanations are most likely?
Analysis (Prioritizing Hypotheses)
The most likely explanation for Mrs. Harris’s clinical
What explanations are most likely? What is the most serious
presentation is acute decompensated heart failure,
explanation? What is the priority order for safe and effective care?
In order of priority, identify the top 4 client conditions.
resulting in impaired perfusion and fluid overload. Her
history of CAD, HTN, and recent symptoms of fatigue,
dizziness, edema, and crackles align with this medical
condition. The low blood pressure and elevated heart
rate suggest that her heart is struggling to maintain
adequate circulation.
Page 2 of 13
DIRECT-FOCUSED CARE: CONCEPT MAPPING ASSIGNMENT WORKSHEET
NURSING PROCESS TEMPLATE: Concept- Perfusion
Assessment (Recognizing Cues) Evelyn Harris is a 76-year-old female admitted to the
medical-surgical unit with complaints of increased
Which client information is relevant? What client data is most
fatigue, dizziness when standing, and swelling in her
important? Which client information is of immediate concern?
ankles. Her daughter reports that she has been "more
Consider signs and symptoms, lab work, client statements, H &
P, and others. Consider subjective and objective data. tired than usual" over the past few days and “can’t walk
as far without needing to sit down.”
Medical Hx: Congestive heart failure (CHF), hypertension
(HTN), hyperlipidemia (HLD), and coronary artery disease
(CAD). She had a stent placed two years ago
Subjective Data:
"more tired than usual"
“can’t walk as far without needing to sit down.”
Objective Data:
VS: Temp 98.7F, 108HR, RR20, 88/54, pain 0/10,
O2 Sat 92%RA
Pale, cool skin on extremities
Bilateral (BL) +2 pitting edema in ankles
Capillary refill > 3 seconds
Jugular vein distention noted when sitting upright
Lung sounds: crackles at bases bilaterally
Labs: Hemoglobin 10.2g/dL, Hematocrit 31%,
BNP 640pg/mL, Troponin normal range, Sodium
132mEq/L, Creatinine 1.5mg/dL
Immediate Concern:
Hypotension indicating signs of decreased cardiac
output
O2 Sat 92%RA with presence of crackles indicate
potential pulmonary congestion
BNP level elevated indicating possible worsening
heart failure
Low hemoglobin and hematocrit which can
impair oxygen delivery to the tissues in the body
Elevated creatinine which may indicate
decreased renal perfusion
Client conditions that are consistent with the cues:
Analysis (Analyzing Cues)
The cues all strongly suggest the patient is experiencing
Which client conditions are consistent with the cues? Do the cues
decreased cardiac output and possible congestive heart
support a particular client condition? What cues are a cause for
concern? What other information would help to establish the
failure (CHF).
significance of a cue?
Client conditions that are consistent with the cues:
Elevated BNP is a biomarker indicating ventricular
stretch and fluid overload which is commonly
seen in heart failure
Hypotension and tachycardia are signs the heart
is not pumping effectively
Pulmonary crackles and low O2 saturation
Page 1 of 13
, suggest fluid backing up into the lungs
Peripheral edema and jugular vein distention
indicate fluid retention and increased venous
pressure.
Fatigue and dizziness suggest there is reduced
tissue oxygenation due to poor perfusion.
What cues are a cause for concern:
Hypotension with blood pressure of 88/54mmHg
can reduce organ perfusion and lead to further
complications.
Tachycardia with heart rate of 108 bpm may be a
compensatory response but also increases the
cardiac workload.
Crackles in lungs and O2 sat of 92%RA indicate
pulmonary congestion and risk of respiratory
compromise.
BNP level confirms significant cardiac strain.
Increased creatinine levels may indicate
decreased renal perfusion and early kidney
involvement.
Pale, cool skin and delayed capillary refill show
peripheral circulation is compromised.
What other information would help to establish the
significance of a cue?
Echocardiogram results would provide
information regarding the ejection fraction and
overall heart function.
Intake and output records help assess fluid
balance and influence diuretic management.
Vital signs trends and weight could confirm
worsening or improvement of heart failure
symptoms.
Medication adherence history to determine if
worsening symptoms might be due to missed
doses or ineffective therapy.
Electrolyte panel and liver function tests to assess
for other organ involvement due to reduced
perfusion
What explanations are most likely?
Analysis (Prioritizing Hypotheses)
The most likely explanation for Mrs. Harris’s clinical
What explanations are most likely? What is the most serious
presentation is acute decompensated heart failure,
explanation? What is the priority order for safe and effective care?
In order of priority, identify the top 4 client conditions.
resulting in impaired perfusion and fluid overload. Her
history of CAD, HTN, and recent symptoms of fatigue,
dizziness, edema, and crackles align with this medical
condition. The low blood pressure and elevated heart
rate suggest that her heart is struggling to maintain
adequate circulation.
Page 2 of 13
