Megan Politano – Critical Care Concept Map

Key Problem #1 Key Problem #2 Key Problem #3

Impaired Gas Exchange Ineffective Airway Clearance Ineffective Breathing
Pattern
Supporting Data: Supporting Data:
 Diminished breath sounds  Diminished breath sounds Supporting Data:
and wheezes upon and wheezes upon  Patient is on ventilator
assessment assessment o AC Mode
 Uncompensated metabolic  Ineffective cough o Rate: 23
alkalosis  History of chronic smoker o FiO2: 90%
 Chest x-ray: atelectasis over 40 years o TV: 440
 Diagnosis of chronic  Roto bed o PEEP: 19
smoker over 40 years

Reason For Needing Health Care (Medical Key Problem #5

Key Problem #4
Diagnosis): Infection
Excess Fluid Volume
Pneumonia due to organisms (Rhinovirus)
Acute respiratory failure with hypoxia and Supporting Data:
Supporting Data:
hypercapnia  Pneumonia due to
 Non-pitting edema
rhinovirus
bilateral upper
Key Assessments:  Patient placed in
extremities
Respiratory Status droplet and contact
 +1 pitting edema
isolations
bilateral lower Allergies: No Known Allergies  Azithromycin
extremities
(zithromyocin): 500
mg: 250 mL//hr
 Ceftriaxone
(rocephin): 1 g

Key Problem #6 Key Problem #7 Key Problem #8

Impaired Physical Impaired Verbal Risk for Acute Confusion
Mobility/Risk for Impaired Communication and Acute Pain
Skin Integrity
Supporting Data: Supporting Data:
Supporting Data:  Patient is intubated
 Sedated and intubated
 Patient sedated and  Patient is sedated and
 Diagnosis of
paralyzed paralyzed Schizophrenia, paranoid
 Patient placed in Roto  Does not respond to name,
 Diagnosis of
bed touch, or painful stimuli Schizoaffective disorder,
 Preventative dressings
bipolar type
over bony prominences
 History of Drug
(due to Roto bed)
overdose
 Diagnosis of Acute
Psychosis
Problem # 1: Ineffective Airway Clearance

General Goal: Increased and Improved Gas Exchange

Predicted Behavioral Outcome Objective(s): The patient will have a pulse oximeter reading of
> 92% Q1hr, ABGs within normal range, and absence of adventitious breath sounds on the day
of care

Nursing Interventions:
1. Assess vital signs, especially respiratory rate and pulse oximetry
2. Auscultate lungs and assess breath sounds – noting rate, depth, and easy of respiration
3. Monitor blood gas values and pulse oxygen saturation levels as available
4. Assess patient’s chest x-ray
5. Assess for signs and symptoms of oxygen toxicity
6. Position client to optimize respiration
7. Monitor patient’s behavior and mental status for the onset of restlessness, agitation,
confusion, or extreme lethargy
8. Observe for cyanosis of the skin; especially not color of tongue and oral mucous
membranes

Patient Responses:
1. During the shift, the patient’s vital signs ranges included temperature from 37.4-27.6 C,
BP 100/66 – 122/83, MAP 76-99, HR 108-116, RR 23, and SpO2 98-100%
2. Breath sounds were diminished and wheezes were present during auscultation. The
patient did not have a productive cough.
3. Blood gases available during day of care: pH of 7.488 (), PCO2 of 42.3 (WNL), PO2 of
57.4 (), and HCO3 of 31. 4 () = Uncompensated metabolic alkalosis
4. Chest x-ray results for day of care: worsening bilateral infiltrate. Underlying tumor in left
hemithorax medially is not excluded. Some worsening infiltrate in the right lobe.
Atelectasis in right upper lobe.
5. No signs and symptoms of oxygen toxicity were present during shift.
6. Client was placed in Roto bed for optimal positioning – patient was not prone during
shift.
7. Patient was sedated, paralyzed, and intubated during day of care.
8. No cyanosis present. Skin was warm and appropriate for ethnicity. Mucous membranes
were pink and moist.

Evaluation of outcomes objectives: Goal was partially met. Patient’s pulse oximeter readings
were maintained between 98-100% during shift (goal met). ABGs on day of care were not within
normal range – uncompensated metabolic alkalosis was interpreted (goal not met). During
assessment, adventitious breath sounds were present – diminished and wheezes (goal not met).
Problem # 2: Impaired Gas Exchange

General Goal: Increased Airway Clearance

Predicted Behavioral Outcome Objective(s): The patient will have increased bilateral breath
sounds and a productive cough to remove secretions on day of care.

Nursing Interventions:
1. Auscultate breath sounds
2. Monitor respiratory rate, depth, and ease of respirations – watch for accessory muscles
use and nasal flaring
3. Administer DuoNeb (Respiratory Therapy)
4. Monitor oxygen saturation continuously using pulse oximetry
5. Hyperoxygenate patient and suction PRN
6. Mouth care Q4hrs
7. Position the patient in a position with the HOB at 30-45 degrees angle to decrease the
aspiration of gastric, oral, and nasal secretions
8. Turn the patient every 2 hours and promote deep breathing and coughing

Patient Responses:
1. Breath sounds were diminished during every 2 hour assessment. Wheezes present
throughout shift.
2. Patient was ventilated. RR 23. Regular rate, depth and ease of respirations. No accessory
muscle use and nasal flaring present.
3. Respiratory therapy administered DuoNeb at 1600 and 2000 during shift
4. Oxygen saturation was continuously monitored during shift. SpO2 was maintained
between 98-100% throughout day of care.
5. Patient was suctioned PRN
6. Mouth care was provided at 1600 during day of care
7. Patient was placed in Roto bed
8. Patient was placed in Roto bed. Unable to promote deep breathing and coughing due to
sedation and intubation.

Evaluation of outcomes objectives: Goal was not met. Patient did not have increased bilateral
breath sounds and patient presented with no cough to remove sections (patient was suctioned
PRN) on day of care.
Problem # 3: Ineffective Breathing Patterns

General Goal: Improved Breathing Patterns and Maintain Ventilation

Predicted Behavioral Outcome Objective(s): Patient will present and maintain an effective
breathing pattern, at normal depth and rate without signs of dyspnea on day of care

Nursing Interventions:
1. Assess ventilator settings
2. Assess for hemodynamically stability for acute dyspnea
3. Monitor SpO2 and respiratory rate, depth, and ease of respirations – Note pattern of
respiration. If client is dyspneic, note what seems to cause dyspnea, the way in which the
client deals with the condition, and how the dyspnea resolves or gets worse
4. Monitor RASS Score
5. Suction PRN
6. Observe color of tongue, oral mucosa, and skin for signs of cyanosis
7. Auscultate breathe sounds, noting decreased or absent sounds, crackles, or wheezes
8. Evaluate the client’s nutritional status which may increase inspiratory muscle function

Patient Responses:
1. Ventilator settings include: AC mode, Rate 23, FiO2 90%, TV 440, PEEP 19
2. Patient was hemodynamically stable. VS stable throughout shift and MAP was
maintained > 65
3. SpO2 and RR were WNL during day of care. No dyspnea present.
4. RASS score was -4. Ordered sedation was Versed
5. Patient was suctioned PRN
6. Tongue and oral mucosa was pink and moist. Skin was warm and appropriate for
ethnicity.
7. Diminished and wheezes present bilaterally
8. NPO status and no diet was ordered during day of care. Albumin level was 4.3 (WNL),
Calcium was 8.6 (WNL), Potassium was 3.9 (WNL), and total protein was 7.3 (WNL).

Evaluation of outcomes objectives: Goal was partially met. Patient had a normal rate and
rhythm of respiratory status. Patient was on ventilator. No signs of dyspnea were present on day
of care.
Problem # 4: Excess Fluid Volume

General Goal: Balanced Fluid Volume

Predicted Behavioral Outcome Objective(s): Patient will have a minimum of 30 cc/hr,

decreased edema, and serum laboratory values WNL on day of care

Nursing Interventions:
1. Assess BP and MAP
2. Assess for edema
3. Assess hourly output and sssess urine – color, clarity, and amount
4. Monitor I&O
5. Monitor Renal Function and abs – including AST, ALT, BUN, Creatinine, GFR
6. Assess labs – BNP, serum electrolytes, H&H
7. Assess fluid balance
8. Check Foley and provide Foley care

Patient Responses:
1. Patient’s BP was 100/66 – 122/83 and MAP was between 76-99 during shift
2. Edema was present in upper and lower extremities. Non-pitting edema bilaterally upper
extremities. +1 pitting edema bilaterally lower extremities
3. Hourly urine was between 25-50 cc/hr. 1500: 50 cc, 1600: 30 cc, 1700: 25 cc, 1800: 25
cc, 1900: 30 cc. Urine was straw color, yellow, and total of 160 cc during shift
4. I&O: 6 hour intake was 250, 6 hour output was 450; 24 hour intake was 708.1 and 24
hour output was 1635
5. Renal function lab results include AST of 16 (WNL), ALT of 18 (WNL), BUN of 14
(WNL), Creatinine of 1.2 (WNL), and GFR > 60 (WNL)
6. Lab results include BNP of 147 (), Sodium of 136 (WNL), Potassium of 3.9 (WNL),
Chloride of 98 (WNL), Calcium of 8.6 (WNL), Hemoglobin of 12 () and Hematocrit of
39.5 (WNL)
7. Cumulative Fluid Balance for prior day was -926.9
8. Foley was intact and care was provided

Evaluation of outcomes objectives: Goal was partially met. The patient had an hourly output
around 30cc, but 25cc were put out during 1700 and 1800. The patient presented with edema
during day of care. Lastly, majority of the labs were WNL, but BNP and hemoglobin were not
within normal limits during day of care.
Problem # 5: Infection

General Goal: Patients remains free of infection

Predicted Behavioral Outcome Objective(s): Patient will not exhibit any signs of infection and
will have normal vital signs during day of care

Nursing Interventions:
1. Administer azithromycin
2. Administer Ceftriaxone
3. Monitor for signs and symptoms of infection such as redness, warmth, discharge, and
increased body temperature
4. Oral, rectal, tympanic, temporal artery or axillary thermometers may be used to check
temperature throughout shift
5. Note and report laboratory values, especially white blood cell count and differential,
serum protein, serum albumin, and cultures
6. Carefully wash and pat dry skin, including skinfold areas. Use hydration and
moisturization on all at-risk surfaces
7. Use appropriate hand hygiene
8. Follow standard precautions and wear gloves during any contact with blood, mucous
membranes, nonintact skin, or any body substances except sweat

Patient Responses:
1. Azithromycin (Zithromax) was administered through IV. The dose was 500 mg: 250
mL/hr. This is an agent for atypical mycobacterium anti-infectives
2. Ceftriaxone (Rocephin) was administered through IV. The dose was 1 g in sterile water
10 mL IV syringe. This is an anti-infective that has a bactericidal action against
susceptible bacteria.
3. Patients did not present with signs and symptoms of infection.
4. Bladder temperature was between 37.4-27.6 C during shift
5. Laboratory values include WBC of 8.4 (WNL), neutrophils 68.5 (WNL), lymphocytes of
15.5 (), monocytes of 12.9 (), eosinophils of 2.0 (WNL), basophils of 0.5 (WNL),
protein was 7.3 (WNL), and albumin was 4.3 (WNL)
6. Patient was bathed during day of care. Patient had preventative dressings over bony
prominences to prevent skin breakdown from roto bed
7. Appropriate hand hygiene was performed at times of entering and leaving the room and
when in contact with the patient.
8. Contact and droplet isolation precautions were put in place and utilized throughout shift
when caring for the patient.

Evaluation of outcomes objectives: Goal was met. Vital signs were within normal limits and
patient did not present signs of infection during day of care.
Problem # 6: Impaired Physical Mobility/Risk for Impaired Skin Integrity

General Goal: Improved Physical Mobility and Improved Skin Integrity

Predicted Behavioral Outcome Objective(s): The patient will perform passive ROM exercises
and the patient will not have any signs of skin breakdown on day of care.

Nursing Interventions:
1. Provide daily care measures regarding self-care, hygiene, mouth care
2. Monitor vital signs
3. Activity restrictions
4. If the client is immobile, perform passive ROM exercises at least 2 times a day
5. Turn patient every 2 hours
6. Monitor for skin breakdown and assess for skin impairment and determine cause or type
of wound
7. Assess client’s nutritional status to promote proper healing
8. Increase independence in ADLs, encourage self-efficacy, and discourage helplessness as
the client get stronger

Patient Responses:
1. Patient was bathed and had mouth care performed Q4hrs during day of care
2. VS were WNL during day of care
3. Patient was sedated and paralyzed
4. Patent was in roto bed – passive ROM exercises were not performed
5. Patient was in roto bed
6. No skin breakdown noted. Patient had preventative dressings over bony prominences to
prevent skin breakdown from roto bed
7. Patient was NPO with no diet orders. Labs were WNL.
8. Not performed during shift due to sedation and paralytic. Should be included in discharge
instructions.

Evaluation of outcomes objectives: Goal was partially met. There were no signs of skin
breakdown during day of care. Passive ROM exercises were not performed due to patient in roto
bed on day of care.
Problem # 7: Impaired Verbal Communication

General Goal: Effective Communication

Predicted Behavioral Outcome Objective(s): The patient will respond with appropriate non-
verbal behaviors to verbal command or physical stimuli on day of care

Nursing Interventions:
1. Use comprehensive nursing assessment to determine the language spoken, cultural
considerations, literacy level, and cognitive level
2. Neurological assessment
3. Assess RASS score
4. Assess ETT tube and cuff pressure every shift and PRN
5. Validate verbal and nonverbal expressions particularly when dealing with pain and use
appropriate scales for pain
6. Use therapeutic communication techniques: speak in a well-modulated voice, use simple
communication, maintain eye contact at the client’s level, get the client’s attention before
speaking, and show concern for the client
7. Use touch as appropriate
8. Use consistent nursing staff for those with communication impairments

Patient Responses:
1. Patient was sedated and intubated during shift
2. Sedated with RASS score of -4. Patient did not respond to name, touch, or painful
stimuli. Pupils were 1mm, brisk, and round. Face was symmetrical
3. RASS score was -4
4. ETT tube was 8/25. Cuff was inflated.
5. Patient did not respond to name, touch, or painful stimuli
6. Before providing care to patient, I had verbally explained what I was doing before
touching the patient. Even though the patient was sedated, I had still talked to them as if
they could hear me.
7. Therapeutic touch was used when talking to patient
8. Consistent nursing staff used for patient due to condition.

Evaluation of outcomes objectives: Goal was not met. Patient did not respond with nonverbal
behaviors to verbal command of physical stimuli on day of care. Patient did not show signs of
pain or discomfort during care.
Problem # 8: Risk for Acute Confusion and Acute Pain

General Goal: Patient will not present with acute confusion and show no signs of symptoms of
acute pain

Predicted Behavioral Outcome Objective(s): Patient will be alert and oriented about hospital
stay and demonstrate restoration of cognitive status to baseline prior to discharge. During day of
care, patient will maintain a CPOT score of 2 or lower.

Nursing Interventions:
1. Sedation vacations
2. Monitor RASS score
3. Obtain an accurate history and preform and metal status exam
4. Monitor CPOT score
5. Monitor ventilator settings (AC to PSV)
6. Reorient patient upon awaking and PRN
7. Treat pain with non-pharmacological measures and pharmacological PRN
8. Relieve patient from anxiety with distraction and relaxation techniques

Patient Responses:
1. No sedation vacations were performed during day of care
2. RASS score was -4 during shift
3. Patient did not respond to voice, touch, or painful stimuli
4. CPOT score was 0 during shift and was assessed Q2hrs
5. Ventilator settings was maintained on AC mode
6. Patient did not awaken during shift
7. CPOT score was 0 therefore, no pain relief measures implemented
8. Patient was sedated and no signs of anxiety shown

Evaluation of outcomes objectives: Unable to assess presents of acute confusion due to

sedation of patient. Goal was met regarding pain. CPOT score was 0 during day of care.