Assessment and Concept Map Care Plan for Critical Care

Patient

Created by

Valerie R. Kinsey
Senior Nursing Student
Youngstown State University
Youngstown, Ohio
 Critical Care Patient Case Study Data

Student: Valerie Kinsey

Date of Care: 2/14/2020

Pt’s Initials: A.T. RM No. 10-A Age: 35 Sex: F Date admitted: 2/12/20

DNR status: Full Code

Allergies: NKA Height: 5’ 8” Weight: 119.3 kg Isolation type: Standard Precautions

Diagnosis(es): Trauma – Multiple Stab Wounds (hemorrhagic shock, hemopneumothorax (Rt), intraabdominal
hemorrhage, laceration of the diaphragm, spleen injury, laceration of the scalp, laceration of bilateral hands)

Reason for Admission/Events Leading to Concurrent Hospitalization and reason in unit for >2 days (if
appropriate):

Presented to the ED with multiple stab wounds (intimate partner violence). Pt was hypotensive and tachycardic.
Found to have hemopneumothorax with right lateral chest tube. Blood Transfusion on admission. Admitted to
the SICU intubated after a splenectomy d/t stab wound to damage spleen.

Pertinent History of Illnesses/Surgery:

Laparotomy – Splenectomy performed (2/12/20). No smoking, alcohol, drug hx.

No known medical hx.

Day before clinical Day of Care

T 97.8 T 97.9

BP 148/90 BP 143/87

MAP 109 MAP 104

RR 16 RR 14

HR 103 HR 96

Oxygenation: 2 L/min via N/C

Extubated – 2/13/20
Neurological:
LOC: Alert/Fatigued Orientation: x4 (person, place, time, Ordered Sedation: none
situation)
Opens Eyes: yes GCS: X Pupils: 3mm, PERRLA
Speech: Raspy Tongue: No deviation Face Symmetry: Symmetrical

Cardiovascular:
Rhythm: NSR Pulse: Regular/Irregular Heart Sounds: S1 S2
JVD: none Cap Refill: (<3 sec) (>3 sec) CVP: X PCWP: X
Cyanosis Location: X Pacemaker: X

Peripheral Vascular:
Pulses: (Palp or Doppler) Radial: R +2 L +2 Pedal: R +2 L +2
Edema: Yes /No Location: Generalized Degree: Non pitting

Respiratory:
Breath Sounds: Clear/Diminished Sputum: Pt. c/o inability to cough up sputum
Chest Tubes (Location/system/Sx setting): Right/Water Seal/ Cough: Y / N (Productive/Nonproductive)

GI:
Diet: Clear Liquid TPN X TF (type/rate): X
NG/OG/PEG/FT (circle) NG Sx Drainage: X Abdomen: soft distended tender
Bowel Sounds: hypoactive x4 Stool: Y / N (1 occurrence) Incontinent: Y / N
Ostomy (type): X FMS: X Color/charac: dark brown, loose

GU:
Urine: Color Yellow Clarity Clear Amount 200 mL Catheter Type/size: Foley
Genital Irritation: Y / N Dialysis (type/site): X

Skin:
Temp: 97.6 Warm to touch Color: Appropriate for ethnicity Turgor: Elastic Mucous Membranes: Moist/Pink
Incisions: Abdominal Surgical Incision (Splenectomy/Laparotomy), Chest tube insertion site, Femoral Arterial Line
Wounds: lacerations to scalp, posterior neck, abdomen, chest, L. thigh, and bilateral hands

Musculoskeletal:

Upper Extremities:
Movement – Limited Strength – moderate (Rt) weak (Lt) Sensation – Full (Rt) Numbness/Tingling (LT)

Lower Extremities:

Movement – Limited Strength – Moderate Sensation – Full

IV Drips

Medication Concentration Rate Site Line

Hydromorphone O.2 mg/mL PCA R. Subclavian CVC Triple Lumen
(Dilaudid)
Normal Saline 0.9% NaCl 50 mL/hr R. Subclavian CVC Triple Lumen

24 hr. Intake: 3622 24 hr. Output: 1408 Cumulative Fluid Balance: +2214
Pain Management:
Location: upper back Duration: Acute Scale (0-10): 7 Intervention: PCA (Dilaudid)/ Positioning
Evaluation: Pain dropped from 7 to 4 within 30 minutes

ABG Analysis:

ABG’s: pH PCO2 PO2 HCO3 Interpretation

Admission 7.35 36.2 153.2 19.7 Compensated Metabolic Acidosis

Date:
Day prior X X X X X
Date:
Day of care X X X X X
Date:
*No ABGs Drawn since admission

Diagnostic Test: Results:

Chest X-Ray 2/13/20 (0600) – ET tube removed. R. chest tube placed. No conspicuous R. sided Pneumothorax.
(include date)
Other pertinent 2/12/20 (1311) – CT abdomen w/ contrast – small bilateral pneumothorax on L. side with R. chest tube in
diagnostic tests
place. Fracture of 10th rib. Moderate emphysema. Spleen removed. Colon collapsed with wall thickening.
(include date)
2/12/20 (1326) – CTA Neck w/ contrast – no neck injury

2/12/20 (1316) – CT cervical spine w/o contrast – commuted fracture of C7. Apical pneumothorax.

2/12/20 (1319) – CT chest w/ contrast – fracture L. 9th and 10th rib. Atelectasis and contusions to lung
bases.

2/12/20 (1220) – CT head w/o contrast – R. scalp laceration and hematoma surrounding ext. auditory
canal
 5

Lab Test Normal Values Admission Day prior Day of care

Reason for Abnormal
Date 2/12/20 2/13/20 2/14/20
Na+ 132-146 142 140
K+ 3.5-5.0 4.4 4.2
Cl- 98-107 109 105 Dehydration
CO2 22-29 22 24
BMP

Glucose 74-99 125 116 Trauma (stab)

BUN 8-23 13 13
Creatinine 0.5-1.0 0.7 0.5
Calcium * 8.6-10.2 8.1 8.4 Metabolic acidosis
Albumin 3.5-5.2 3.0 2.6 Shock (trauma)
CMP (+ BMP)

Total protein 6.4-8.3 5.6 5.8 Metabolic acidosis

ALP (Alk Phos) 35-104 50 53
ALT/SGPT 0-32 58 46 Splenectomy
AST/SGOT 0-31 100 70 Splenectomy
Total Bilirubin 0.0-1.2 0.4 0.4
Magnesium 1.2-2.6 1.8 2.1
El

Phosphate 2.5-4.5 3.1 2.2

Cholesterol
Lipid

Triglycerides
RBC 3.50-5.50 3.47 3.20 Trauma (stab)
Hgb 11.5-15.5 9.6 8.5 8.0 Trauma (stab)
Hct 34-48 30.3 27.5 25.7 Trauma (stab)
Platelets 130-450 260 272
CBC

WBC 4.5-11.5 21.6 26.4 Trauma (stab)

neutrophils 43-80 85 93.0 Trauma (stab)
lymphocytes 20-42 5.8 2.6 Trauma (stab)
monocytes 2-12 8.3 4.3
eosinophils 0-6 0.0 0.0
basophils 0-2 0.2 0.1
PT
Coag

INR
HPTT/PTT
CK
Cardiac

CK MB
Troponin
B-type natriuretic peptide
(BNP)
Lactate 0.5-2.2 2.6 1.1 Dec. oxygenation
Other

Ammonia
GFR >60 >60 >60

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

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Lab Test Normal Values Admission Day prior Day of care Reason for Abnormal
Date

*no other labs for date of admission

Pathophysiology of Primary Diagnosis &/or Surgery:

Hemorrhagic Shock – occurs when the body begins to shut down due to large amounts of
blood loss.
Hemopneumothorax – collection of blood and/or air in the pleural cavity
Splenectomy – a surgical removal procedure involving removal of the spleen

Psychosocial Considerations:
Fear, Depression, Body Image Disturbance, Anxiety, Trust issues, Isolation, Regression,
Anger. Does patient have a good support system? Patient may need consultation with
psychiatrist to help work through traumatic event

Medications:
Times Due: 0900 0900 0900
Brand Name Bacitracin Zinc Lidoderm Robaxin
Generic Name Bacitracin Lidocaine 4% Methocarbamol
external patch
Dose 1 application 1 patch 1000 mg
Route/How to Topical Transdermal PO
Administer
Classification Antibiotic Anesthetic Smooth Muscle
Relaxant
Action Prevent infection Stabilize neuronal Skeletal muscle
membranes by relaxant by CNS
inhibiting the ionic depression
fluxes required for
initiation
Reason pt receiving Open wounds Acute pain Acute pain
Contraindications Do not use on large Antiarrhythmics Renal impairment
areas with deep (use with caution) Hypersens. To
puncture wounds local anesthetics polyethylene glycol

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

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Alcohol
Major Adverse/ Rash, itching, Dizziness, Seizures, dizziness,
Side Effects swelling, dizziness, confusion, HA, drowsiness,
trouble breathing N/V, tinnitus, anorexia, N/V,
tremor, dyspnea, hypotension,
shock, metallic bradycardia,
taste, blurred vision
bronchospasm
Nursing Advise to use only Monitor s/s of Assess pain/muscle
Implications on small wounds. adverse reactions. stiffness. Monitor
Do not use with Monitor pain levels. pulse and blood
animal bites. Apply Monitor ECG. pressure q 15 min.
thin layer to cut. monitor renal
Monitor s/s of function.
infection.
Pt/Family Teaching Do not use longer May cause Take as directed.
than 1 week unless drowsiness. Apply Comply with
directed. Do not to intact skin. additional therapy.
apply large Clothes may be Avoid alcohol and
amounts to wound. worn. Wash hands CNS depressants.
before and after May cause
application. drowsiness. May
cause black urine.

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

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Patient’s Clinical Concept Map

#4 Key Problem/ND #1 Key Problems/ND #3 Key Problem/ND

Infection Ineffective Airway Clearance Impaired Tissue (Skin)
Integrity
Supporting Data: Supporting Data
WBC 26.4 Diminished Breath Sounds Supporting Data
Neutrophils 93.0 Pt. c/o inability to cough up Trauma
Impaired Primary Defenses secretions Laceration to Scalp
(broken skin integrity) Weakness of diaphragm d/t Laceration to Posterior Neck
Compromised Circulation laceration Lacerations to Abdomen
Possible Diabetes Mellites Hemopneumothorax Laceration to Bilateral Hands
Splenectomy Previous Intubation Laceration to Left Thigh
Bacitracin Previous Extubation Splenectomy
Chest Tube Insertion Previous Reintubation Chest Tube Insertion
JP Drain to Scalp Laceration JP Drain to Scalp
Femoral Arterial Line Femoral Arterial Line
Foley Catheter

Reason For Needing Health Care

(Medical Dx/ Surgery)
Trauma – Multiple Stab Wounds
Hemorrhagic Shock
Hemopneumothorax (R)
Intraabdominal Hemorrhage
Laceration of the Diaphragm
Spleen Injury  Splenectomy
Laceration of the Scalp
Laceration of Bilateral Hands
Laceration of Posterior Neck

#6 Key Problem/ND #5 Key Problem/ND #2 Key Problem/ND

Fear/ Post-Traumatic Stress Risk for Fluid Volume Deficit Acute Pain
Disorder
Supporting Data Supporting Data
Supporting Data Major blood loss Multiple Stab Wound
Intimate Partner Violence Victim RBC 3.20 Pt c/o pain of 7
Multiple Stab Wounds Hgb 8.0 PCA – hydromorphone
Fear of Death Hct 25.7 Surgical Wound
Tearful Clear Liquid Diet BP 143/87
Anticipation of Pain Generalized Weakness HR 96
Tension 0.9% Normal Saline RR 14
Treatments/ Invasive Procedures Lactated Ringers Generalized Weakness
Unfamiliar environment Strict I&O Requests position change often
Unfamiliar people Foley Catheter Tearful

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

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Problem # ____1___: Impaired Airway Clearance r/t inability to clear secretions from the respiratory tract.
General Goal: Maintain a patent airway at all times

Predicted Behavioral Outcome Objective (s): The patient will demonstrate effective coughing and clear breath
sounds on the day of care.

Nursing Interventions Patient Responses

1. Instruct how to cough effectively 1. Pt. c/o inability to cough d/t

2. Auscultate breath sounds weakness
3. Suction Secretions 2. Breath sounds clear/diminished
4. Position the client to optimize 3. Scant amount of sputum
respirations suctioned
5. Monitor respiratory patterns 4. Pt positioned in semi fowlers
(rate/depth/effort) 5. Rate 14 normal depth and effort
6. Administer medications 6. Respiratory therapy administers
7. Observe Sputum Color/Amount respiratory medications
7. Sputum color clear/thick/scant
amount

Evaluation of outcome objectives: patient was not able to cough up secretions d/t weakness and fatigue during
my shift.

Problem # ___2____: Acute Pain

General Goal: Decrease Pain Level AEB numeric pain rating scale

Predicted Behavioral Outcome Objective (s): The patient will use PCA to manage decreased pain levels (less
than 4/10) on the day of care.

Nursing Interventions Patient Responses

1. Assess pain level 1. Patient states pain level of 7

2. Administer pain medication 2. PCA decreased pain level to 4
3. Position the client for comfort 3. Responding well to repositioning
4. Premedicate before nursing care 4. Patient still in pain during care
5. Teach non pharmacologic measures 5. Pt. responds well to rest/dim lights
Evaluation of outcome objectives: Patient’s pain level decreased throughout shift. Patient responds well to
repositioning, rest, dim lights. Patient also distracted from pain during family visit.

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

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Problem # ____3___: Impaired Tissue (Skin) Integrity

General Goal: Regain integrity of skin surface

Predicted Behavioral Outcome Objective (s): The patient will Demonstrate understanding of plan to heal skin
and prevent reinjury on the day of care.

Nursing Interventions Patient Responses

1. Assess sites of skin impairment 1. UTA d/t dressing
2. Monitor for infection 2. No s/s of infection – drainage, redness
3. Do not position client on site 3. Site elevated off of bed with pillows
4. Assess nutritional status 4. Patient on clear liquid diet
5. Monitor for incontinence 5. Patient incontinent of stool x1; foley

Evaluation of outcome objectives: Patient’s skin is in healing process. Dressings clean dry intact.

Problem # ___4____: Infection

General Goal: Remain free from symptoms of infection
Predicted Behavioral Outcome Objective (s): The patient will maintain WBC count and differential within
normal limits on the day of care.

Nursing Interventions Patient Responses

1. Observe s/s if infection 1. Pt. shows no s/s of infection

2. Assess temperature 2. Pt. temperature remains 97.8
3. Monitor lab values 3. WBC and neutrophils elevated
4. Encourage fluid intake 4. Pt. drinks minimal fluids d/t weakness
5. Hand hygiene before and after care 5. Pt. does not show s/s of infection
6. Follow standard precautions 6. Pt. does not show s/s of infection
Evaluation of outcome objectives: Patient remains free of s/s of infection throughout shift. However, WBC
and neutrophils elevated on the day of care.

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

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Problem # ___5____: Risk for Fluid Volume Deficit

General Goal: Maintain fluid balance AEB skin turgor, mucous membranes, and urine output

Predicted Behavioral Outcome Objective (s): The patient will maintain elastic skin turgor, moist tongue and
mucous membranes, and orientation to person, place, and time on the day of care.

Nursing Interventions Patient Responses

1. Assess skin turgor 1. Patient’s skin turgor elastic

2. Assess mucous membranes 2. Patient’s mucous membranes
3. Assess BP/Pulse moist/pink
4. Monitor urine output from foley 3. Patient’s BP/Pulse elevated
5. Monitor for electrolyte 4. Patient’s urine output only 200
imbalance mL during shift
5. Patient electrolytes remain
normal

Evaluation of outcome objectives: Patient maintains elastic skin turgor, moist tongue and mucous membranes,
and orientation to person, place, and time during shift.

Problem # ___6____: Fear/ Post-Traumatic Stress Disorder

General Goal: Identify, verbalize, and demonstrate those coping behaviors that reduces own fear
Predicted Behavioral Outcome Objective (s): The patient will report and demonstrate reduced fear on the day
of care.

Nursing Interventions Patient Responses

1. Assess source of fear 1. Pt. is avoidant to talk about trauma

2. Explore coping skills 2. Pt. responds well to visitation
3. Therapeutic touch 3. Pt. requests to hold my hand during care
4. Stay with patient to reduce fear 4. Pt. requests for me to stay in room
5. Encourage patient to talk about fears 5. Pt. is avoidant to talk about trauma
Evaluation of outcome objectives: Patient reports reduced fear when staff is in the room or with family
visitation during shift.

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