1
#1 Key Problem/ND: Impaired Gas
Exchange
Supporting Data:
~ r/t acute respiratory failure
~ intubated A/C mode; switched
to PSV this shift
~ SpO2 99% on 40% FiO2; PEEP
of 5cmH2O
~ ABGs: pH=7.49; PCO2=31.8;
PO2=138.7; HCO3=23.9 
uncompensated respiratory
alkalosis
~ crackles in lung bases
#4 Key Problem/ND: Decreased
Cardiac Output
Supporting Data:
~ diminished urine output
between 5-10cc/hr r/t end stage
renal failure
~ BUN 26
~ Cr 4.7
~ diminished peripheral pulses
(pedal pulses +1 and equal bilat)
~ pt w/ permanent ventricular
pacemaker r/t systolic CHF
~ pt on continuous norepinephrine
to maintain BP
#6 Key Problem/ND: Anxiety
Supporting Data:
~ unfamiliar environment w/
unfamiliar people
~ intubated/sedated w/ continuous
fentanyl
~ lack of understanding of
medical procedures or their
purpose
~ decreased communication d/t
intubation/sedation
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
#2 Key Problems/ND: Ineffective
Airway Clearance
Supporting Data:
~ diminished breath sounds
throughout w/ rhonchi before
and after suction r/t thick
secretions
~ tan to dark red, thick secretions
on suction
~ CXR on 9/11/2019 showed
“significant plural thickening on
R hemithorax; scattered areas of
infiltrates most prominent in
LUL”
Reason for Needing Health Care
(Medical Dx/ Surgery)
Acute Respiratory Failure r/t Sepsis
85 year old male; full code; NKA
Key Assessments: Vital signs, I&O, fluid
balance, labs, ABGs, thorough respiratory
assessments
#7 Key Problem/ND: Risk for
Impaired Tissue Integrity
Supporting Data:
~ bed rest
~ intubated/sedated
~ malnutrition
~ altered circulation/tissue
perfusion
~ redness on coccyx area
Evaluation of Outcomes
#3 Key Problem/ND: Fluid
Volume Overload
Supporting Data:
~ pale yellow, clear urine
~ diminished urine output
between 5-10cc/hr
~ +1 pitting edema of bilat
lower extremities
~ chloride 96 and trending
down (101 from 2 days prior)
~ sodium 137 and trending
down (140 from 2 days prior)
~ BUN 26
~ Cr 4.7
#5 Key Problem/ND:
Imbalanced Nutrition: Less
than Body Requirements
Supporting Data:
~ albumin 3.2 and trending
down (3.3 from previous day)
~ total protein 5.7 and trending
down (5.8 from previous day)
~ calcium 8.9 and trending
down (9.0 from previous day)
~ RBC 3.42
~ Hgb 9.4
~ Hct 30.9
Don’t know how these fit with
the problems??
~ bilirubin 1.3
~ troponin 1.7 w/ no
documentation of cardiac arrest
 2

Problem # 1: Impaired Gas Exchange r/t bilateral pneumonia

General Goal: Patient will maintain adequate ventilation

Predicted Behavioral Outcome Objective (s): Patient will maintain SpO2 > 92%, PaO2 > 60, PCO2 35-45,
and RR 10-20 on the day of care

Nursing Interventions Patient Responses

1. Assess and document the mode of 1. A/C  PSV, no rate, FiO2 40%, no Vt
ventilation, Vt, FiO2, RR, PEEP w/ PSV, PEEP 5, PSV 10
2. Auscultate bilateral breath sounds every 2. Diminished throughout; rhonchi
hour bilateral upper lobes
3. Monitor respiratory rate 3. Maintaining RR of 15-24 on PSV
4. Turn patient Q2h for optimal ventilation 4. Patient desatted while turning but
rebounded quickly once at rest
5. Monitor patient for signs of respiratory 5. Patient tachypneic at times; no signs of
distress restlessness, confusion, or anxiety
6. Assess ABGs  be alert to decreasing 6. On day of care pH=7.49, PCO2=31.8,
PaO2, increasing PCO2, and acidosis PaO2= 138.7, HCO3=23.9
(uncompensated respiratory alkalosis)
7. Monitor SpO2 7. Between 99-100% all shift
8. Elevate HOB at least 30 degrees 8. Patient maintained adequate SpO2

Evaluation of outcome objectives: OUTCOME MET. Patient weaned to PSV and maintained RR 15-24, SpO2
99-100%

Problem # 2: Ineffective Airway Clearance

General Goal: Patient will have effective airway clearance

Predicted Behavioral Outcome Objective (s): Patient will maintain patent airway AEB the absence of
adventitious breath sounds, ability to cough up secretions, and no s/s of respiratory distress on the day of care.

Nursing Interventions Patient Responses

1. Auscultate bilateral breath sounds every hour
and with any change in position; note quality
and presence of adventitious breath sounds
2. Assess SpO2
3. Monitor closely for s/s of respiratory distress
4. Elevate HOB at least 30 degrees
5. Suction only as needed
6. Monitor patients hydration status
7. Turn patient Q2h to promote ventilation
8. Evaluate CXR
1. Diminished throughout; rhonchi noted in
bilateral upper lobes
2. Maintained between 99-100% all shift
3. No signs of restlessness or anxiety
4. Patient tolerated well; maintained SpO2
5. Suctioned tan to dark red, thick secretions
6. Turgor elastic; yellow urine w/o sediment
7. Patient desatted while turning but rebounded
quickly once at rest
8. Significant plural thickening R hemithorax;
scattered areas of infiltrates- prominent LUL

Evaluation of outcome objectives: OUTCOME MET. Patient SpO2 maintained between 99-100%, RR
maintained between 15-24, capillary refill < 3seconds, occasional strong cough
Evaluation of Outcomes

Problem # 3: Fluid Volume Overload

General Goal: Patient will maintain adequate fluid volume status

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

 3

Predicted Behavioral Outcome Objective (s): Patient will have normal fluid volume status AEB balanced
I&O, urinary output > 30cc/hr, HR between 60-100

Nursing Interventions Patient Responses

1. Weigh patient daily 1. 159lbs 13.3oz on day of care

2. Assess and manage signs of
hypervolemia
3. Monitor labs; i.e. sodium, BUN, Cr
4. Monitor and document I&O every hour
5. Monitor Hgb and Hct levels
6. Monitor ABGs for acid-base imbalances
7. Auscultate heart sounds and monitor BP
8. Monitor additional signs of FVO
2. Turgor elastic, mucous membranes pink
and moist, BP 142/51, MAP 81
3. Sodium 137, chloride 96, BUN 26, Cr 4.7
on day of care
4. Intake ~350cc and output 30cc this shift
5. RBC 3.42, Hgb 9.4, Hct 30.9
6. pH=7.49, PCO2=31.8, PaO2=138.7,
HCO3=23.9
7. No extra heart sounds heard, NSR, HR
between 75-96bpm, BP 142/51, MAP 81
8. +1 pitting edema noted in BLE

Evaluation of outcome objectives: OUTCOME PARTIALLY MET. Sodium, chloride, RBC, Hgb, Hct all low
indicating hemodilution and FVO; BUN and Cr high indicating decreased kidney function; decreased urinary
output and +1 pitting edema indicating maldistribution of circulating volume

Problem # 4: Decreased Cardiac Output r/t congestive heart failure

General Goal: Patient will maintain cardiac output

Predicted Behavioral Outcome Objective (s): Patient will maintain BP >120/80, MAP >60, HR 60-100 on the
day of care.

Nursing Interventions Patient Responses

1. Monitor urine output 1. Output between 5-10cc/hr

2. Monitor BUN and Cr levels 2. BUN 26, Cr 4.7
3. Monitor capillary refill and peripheral pulses 3. Capillary refill < 3 seconds, pedal pulses +1
4. Monitor BP, MAP, and HR 4. BP 142/51, MAP 81, HR 75-96
5. Monitor for s/s hypoxemia 5. No s/s of restlessness, confusion, tachycardia,
tachypnea, dyspnea, or fatigue
6. Monitor BNP 6. BNP 56,114
7. Assess and document cardiac dysrhythmias 7. NSR maintained all shift, S1 and S2 were the
and/or extra heart sounds only sounds auscultated
8. Assess skin color and temperature 8. Skin color appropriate with mild ruddiness of
BLE, skin warm to touch

Evaluation of outcome objectives: OUTCOME PARTIALLY MET. Patients BP, MAP, and HR maintained
with norepinephrine, no signs of early hypoxemia, and no extra heart sounds. Decreased urine output noted
throughout shift, and increasing BUN and Cr indicates decreased kidney perfusion and fuction.

Evaluation of Outcomes
Problem # 5: Imbalanced Nutrition: Less than Body Requirements r/t increased metabolic demands d/t
sepsis
General Goal: Patient will have adequate nutrition
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
 4

Predicted Behavioral Outcome Objective (s): Patient will be at or above his previous weight on the day of
care.
Nursing Interventions Patient Response

1. Weigh patient daily 1. 159lbs 13.3oz on day of care, 160lbs

2. Monitor albumin and total protein levels
3. Record I&O and carefully track trends
4. Monitor appearance of skin
5. Observe and document and areas of skin
breakdown
6. Assess OGT residual Q4h while
receiving tube feed
7. Monitor blood glucose levels Q4h
0.9oz previous day
2. Albumin 3.2 and trending down (3.3
previous day), total protein 5.7 and
trending down (5.8 previous day)
3. Cumulative fluid balance on previous
day -709cc, day of care +320cc
4. Skin warm and dry to touch, turgor
elastic, color appropriate with mild
ruddiness of BLE, mucous membranes
pink and moist
5. No areas of skin breakdown; redness on
coccyx but patient turns preformed Q2h
6. Did not assess residual because patient
NPO this shift
7. Glucose 126 at 0700 and 131 at 1100

Evaluation of outcome objectives: OUTCOME NOT MET. Daily weight was lower than previous day, +1
pitting edema indicates third spacing of fluids, albumin and total protein trending down indicating
malnutrition.

Problem # 6: Anxiety r/t actual or perceived health status

General Goal: Patient comfort

Predicted Behavioral Outcome Objective (s): Patient will exhibit a decrease in irritability AEB a calm
demeanor, HR between 60-100, and absence of tachypnea on the day of care.

Nursing Interventions Patient Responses

1. Reassure the patient that he will not be left alone
2. Explain all procedures before they are initiated
3. Describe the purpose of all alarms
4. Provide patient with alternate means of
communication
5. Evaluate patients need for pain control
and administer analgesics as needed
6. Perform a sedation vacation every 24 hours
to assess if patient can tolerate mechanical
ventilation without sedation
7. Monitor patients HR and RR
1. Patient was calm, and his daughter was by his
daughter was by his side all morning
2. Patient was receptive to explanation of
procedures and kept eye contact throughout
3. Patient listened while I explained that alarms
are to alert staff in the event of a problem
4. Once patient weaned off of sedation, he was
able to write to communicate
5. Patient shook head “no” when asked if he
was in pain.
6. Patient weaned from sedation at 0830 and
was still tolerating intubation well
7. HR between 75-96, RR between 15-24

Evaluation of outcome objectives: OUTCOME MET. Patient maintained HR between 60-100 all shift, and
only showed signs of tachypnea when turning Q2h.
Evaluation Having his daughter at the bedside had a calming effect
of Outcomes
on the patient, and no other signs of discomfort or distress were noted.
Problem # 7: Risk for Impaired Tissue Integrity r/t excessive tissue pressure, immobility,
shearing/friction forces, and altered circulation
P. General Goal:
Schuster, Maintain
Concept intact skinAand
Mapping: mucousThinking
Critical membranesApproach, Davis, 2002.
 5

Predicted Behavioral Outcome Objective (s): Patient will have intact skin and mucous membranes on the day
of care.

Nursing Interventions Patient Responses

1. Turn patient Q2h as the patients’
condition allows
2. Elevate HOB at least 30 degrees
3. Float heels bilaterally
4. Minimize friction on tissue during
activity; lift rather than drag patient when
repositioning and transferring
5. Minimize skin exposure to moisture
6. Prevent medical device related pressure
injuries by ensuring that devices are not
placed directly under patient
7. During assessment monitor skin for any
areas of breakdown
1. Patient desatted while turning but his
SpO2 rebounded quickly once at rest
2. Patient tolerated low fowlers position
3. Tolerated well; +1 pitting edema in BLE
4. We utilized the maxislide pad and sky lift
when turning and boosting the patient up
in bed
5. Patient given a bath with foley care and
peri care in the morning; skin dried
immediately after cleansing
6. I made sure no wires, needle caps, etc.
were under the patient when we bathed
him and every time we turned him
7. Patients skin was warm and appropriate
color for ethnicity, mild ruddiness of
BLE, redness of coccyx area

Evaluation of outcome objectives: OUTCOME MET. Patient had intact skin on the day of care; slight redness
on the coccyx area indicates the beginnings of a pressure injury, but interventions to prevent any skin
breakdown are in place.

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

 6

References

Ackley, B. J. (2008). Nursing Diagnosis Handbook: an Evidence-Based Guide to

Planning Care / Betty J. Ackley, Gail B. Ladwig. St. Louis: Mosby/Elsevier.

Baird, M. S., & Bethel, S. (2011). Manual of Critical Care Nursing: Nursing

Interventions and Collaborative Management. St. Louis: Mosby.

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