Brittany Latimer Concept Map 1

Critical Care Patient Concept Map Care Plan

#1 Key Problem/ND #4 Key Problems/ND Key Problem/ND

Impaired Gas Exchange Acute Pain #6 Imbalanced Nutrition: Less
than Body Requirements
Data: Data:
Acute respiratory failure w/ hypoxia Pt. is 7/10 on PAYEN pain score Data:
FiO2 .50 Patient facial expression: Albumin 1.8
ABG’s pH 7.17, pCO2 56.9, PO2, 76, grimacing No TPN ordered until end of
HCO3 21 Agitated shift at 1700
Mechanical ventilation Upper limbs partially bent NPO – 9 days since admission
Pulmonary embolism Tolerating movement NG tube for suction
Current every day smoker

#2 Key Problem/ND
#7 Key Problem/ND
Ineffective Airways Clearance
Reason for Needing Health Care Impaired Verbal
(Medical Dx/ Surgery) Communication
Data:
Diminished breath sounds Perforation of sigmoid colon d/t diverticulitis
Post-splenectomy Data:
Intubation
New ostomy from bowel perforation Pt. intubated for 4 days
ETT suction q2h
Pulmonary embolism Propofol/Fentanyl IV for
Excessive secretions
Sepsis sedation
Hypoxia
Acute respiratory failure w/ hypoxia Hx of depression,
No Coughing
(ventilated) hallucinations, psychotic
Key Assessments: VS, abdomen/bowel, disorder
respiratory
Allergies: clarithromycin, iodine

Key Problem/ND
Impaired Skin Integrity

#3 Data: #5 Key Problem/ND #8 Key Problem/ND

Bowel perforation Hyperthermia Anxiety
Decreased activity
Decreased intake of protein Data: Data:
Dehydration Temp 102.1 F Pt. intubation
Poor nutrition Sepsis Grimacing
Abdominal surgery incision Infection Agitation
Bed rest because of WBC 24.6 (infection) Limited visiting hours for
surgery/ventilation Anesthesia, surgery family
Stoma dusky gray Hot and flushed skin Fear of the unknown
Disruption of skin/tissue RR slightly increased Pain
Post-splenectomy New ostomy bag

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Brittany Latimer Concept Map 2

Problem #1: Impaired Gas Exchange

General Goal: patients gas exchange will be WNL

Predicted Behavioral Outcome Objective (s): The patient will have ABG’s within normal limits and will
remain stable on FiO2 .40 with saturations about 93% on day of care.

Nursing Interventions Patient Responses

1. Assess ABG’s 1. ABGS abnormal

2. Assess breath sounds 2. Breath sounds diminished bilat.
3. Assess SpO2 3. SpO2 100% on .50 FiO2
4. Elevate HOB 30-45 degrees 4. Tolerated HOB raised
5. Assess vent settings 5. FiO2 .50, rate 22, TV 470, PEEP 8
6. Monitor RR, depth 6. RR 26, normal depth

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Brittany Latimer Concept Map 3

Evaluation of outcome objectives: not completely met. ABGs not WNL, patient O2 saturation at 100%.
ABG’s pH 7.17, pCO2 56.9, PO2, 76, HCO3 21

Problem #2: ineffective airway clearance

General Goal: patient airways will have increased clearance

Predicted Behavioral Outcome Objective (s): The patient will have increased breath sounds bilaterally,
coughing will be increased, suctioning will be less frequent, secretions will be thinner on day of care.

Nursing Interventions Patient Responses

1. Suction PRN 1. Pt. needed suction q2-3h. coughing present.

2. Assess breath sounds 2. Breath sounds diminished bilat.
3. Assess secretions 3. Sections thick and dark.
4. Monitor SpO2 4. SpO2 100% FiO2 .50
5. Turn pt. Q2 5. Patient tolerated turning.
6. Administer bronchodilators 6. Bronchodilators tolerated, vasodilation.
7. Monitor RR and patterns 7. RR 26, depth/pattern normal
8. Monitor ABGs 8. ABG’s pH 7.17, pCO2 56.9, PO2, 76, HCO3 21
Evaluation of outcome objectives: Not met. patient secretions thick and dark/green. Breathe sounds still
diminished at end of shift. Suctioning needed q2-3 hrs.

Problem #3: Impaired Skin Integrity

General Goal: patient skin integrity will improve at stoma and incision site.

Predicted Behavioral Outcome Objective(s): patient’s nutritional status will improve when TPN is started on
10/27 (day of care) to help with healing. Albumin will increase.

Nursing Interventions Patient responses

1. Observe wounds, note drainage/smell 1. Wound is vertical down patient’s stomach, foul odor present. Dr. notified.
2. Change dressing prn on incision 2. Pt. tolerate dressing changes.
3. Observe patient stoma 3. Stoma is gray/dusky with no output present
4. Assess nutritional status 4. Albumin 1.8, TPN ordered to start at 1700 on 10/27.
5. Observe for pressure ulcers 5. No pressure ulcers present
6. Provide tissue care as needed 6. Abd. Wound packed with abd pads. Changed by resident.

Evaluation of outcome objectives: objectives not met. Nutritional status has not been improved on this shift.

P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.

Problem #4: Acute Pain

General Goal: patient will have decreased pain
 Brittany Latimer Concept Map 4

Evaluation of outcome objectives: At the end of shift, patient’s pain was a 7 on the PAYEN pain score.

Problem #5: Hyperthermia

General Goal: patient’s temperature will be WNL.

Predicted Behavioral Outcome Objective(s): patient will have a temperature of below 100.4 at end of shift.

Nursing Interventions Patient Responses

1. Monitor temperature 1. Patient temp. is 102.1 F
2. Monitor skin color 2. Skin color is red and flushed
3. Monitor skin temperature 3. Skin temp. is warm to the touch
4. Monitor WBCs 4. WBCs 23.3 on day of care
5. IV fluids 5. Patient has Dextrose in NaCl @ 50ml/hr
6. Antibiotic administration 6. Patient has Fluconazole, Zosyn, Vancomycin running thru IV central line

Evaluation#6:
Problem ofImbalanced
outcome objectives:
Nutrition:Objective
less than not
bodymet. At end of shift, patient temperature is 102.1 F.
requirements
General Goal: Patient’s Nutrition will become well balanced

Predicted Behavioral Outcome Objective(s): patient albumin level will increase above 3 on day of care.

Nursing Interventions Patient responses

1. Monitor the patient’s albumin level 1. Patient’s albumin level is 1.8
2. Daily weight 2. On 10/26 71.4kg, on 10/27 71.5kg
3. Advocate for implementation of feeding protocol. 3. Doctor ordered TPN to begin on 10/27 at 1700.
4. Provide good oral hygiene 4. Patient tolerated mouthcare well
5. Monitor RBC/WBC, these can drop with malnutrition 5. RBC: 2.40, WBC: 23.3 (infection)
6. Monitor serum electrolyte values 6. Potassium: 3.7, sodium 141, Chloride 101
7. Look for physical signs of poor nutritional intake 7. Patient does not physically appear malnourished.
Evaluation of outcome objectives: Objective not met. Patient albumin level is 1.8 on day of care.

Problem #7: Impaired Verbal Communication

General Goal: Effective Communication
P. Schuster,
Predicted Concept
Behavioral Mapping:
Outcome A Critical
Objective(s): Thinking
The patient Approach,
will use Davis, 2002.
effective non-verbal communication techniques on
day of care.
Nursing Interventions Patient responses