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Ashley Dibble Concept Map

Patient: R.C.
Age: 36
Sex: Female
#1 Impaired Spontaneous Ventilation
DNR Status: Full Code
- On Ventilator
- Mode AC
- TV 500
- FiO2 .60
- Rate 16
- PEEP 8
- SpO2 100%
#2 - Continuous IV propofol
- Dry oral mucous membranes (ETT)
- Mouth Care q2h
Ineffective Airway Clearance
- Intubated #4
- ETT
- Continuous IV propofol Disturbed Sensory Perception
- Stasis of secretions - Disoriented to time, place,
- Diminished breath sounds person
- Restlessness - Altered communication
- Weak cough Reason for Needing Health Care: - Stress
- Turn q2h Subarachnoid Hemorrhage - Continuous IV propofol
- WBC 22.2 - Need to be kept at RASS
- Neutrophils 93.8 % Key Assessments: score +1 to -1
- Neuro - Bilateral soft wrist restraints
- Respiratory - Confused facial expressions
- UTA sensation
Allergies:
- Aspirin
#5 - Ibuprofen
#3
Imbalanced Nutrition: Less Than
Body Requirements Ineffective Tissue Perfusion
- NPO - ICP Monitoring
- NG Tube #6 - Art line
- Height 5’ 7” - Continuous BP monitoring
- Weight 240 lbs. on admission Anxiety - BP parameters
- Weight 236 day after admission - Inability to communicate verbally and - Hx Uncontrolled Hypertension
- BMI 37.6 (Obese) effectively - Hx TIA (4/2016)
- Intubated - Inability to breath without support - Hx Smoking .25 packs a day
- Electrolyte Imbalances - Continuous IV propofol
- Hx Hyperlipidemia - Unknown Outcome
- Hx Gestational Diabetes - Intubated
- Restlessness
- Bilateral soft wrist restraints
- Hx Major Depressive Disorder

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

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Problem # 1: Impaired Spontaneous Ventilation

General Goal: Maintain Ventilations

Predicted Behavioral Outcome Objective (s): The patient will tolerate ventilator on ordered settings and have
normal arterial blood gases (ABGs) within client parameters on the day of care.

Nursing Interventions Patient Responses

1. Assess ventilator settings 1. AC Mode, Rate 16, FiO2 .60, TV 500, PEEP 8
2. Monitor SpO2 2. SpO2 100% on ventilator
3. Monitor ABGs 3. pH 7.3, PCO2 43.2, PO2 87.9, HCO3 22.4
4. Titrate Propofol for RASS -1 to +1 4. RASS -1
5. Mouth care q2h & prn 5. Chlorhexidine swabs and suction performed
6. Assess RR, depth, & pattern 6. RR 16, unlabored, regular, no use of accessory
7. Auscultate lungs for normal or adventitious muscles
breath sounds 7. Clear, regular, diminished
8. Document ET tube position 8. ETT 26 at lip line, Size 7.5 mm

Evaluation of outcome objectives:

Outcome was met. The patient tolerated the ventilator, maintained an appropriate RASS score, rested quietly,
was not agitated, and the ABGs were normal.

Problem # 2: Ineffective Airway Clearance/ Risk for Infection

General Goal: Remain free from infection with increased airway clearance

Predicted Behavioral Outcome Objective (s): The patient will show no signs of infection and will have normal
breath sounds after suctioning on the day of care.

Nursing Interventions Patient Responses

1. Auscultate lungs for normal or adventitious 1. Diminished, clear, unlabored, regular breath
breath sounds sounds
2. Assess secretions 2. Thin and clear
3. Hyperoxygenate before, during and after 3. Decreased risk of hypoxia
suctioning 4. Cleared secretions and reduced hypoxia
4. Suction PRN 5. Improve breathing
5. Administer DuoNeb 6. 22.2 (abnormally high)
6. Monitor WBCs 7. HOB 30-45, oral care, suctioning, PUD
7. VAP Protocols prophylaxis (Protonix), VTE Prophylaxis (PCDs)
8. Turn client q2h 8. Mobilizes secretions to help prevent VAP

Evaluation of outcome objectives:

Outcome was partially met. Patient responded well to being suctioned and had clear breath sounds after
suctioning when needed. WBCs were elevated and could be an indicator of infection.

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

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Problem # 3: Ineffective Tissue Perfusion

General Goal: Improve Tissue Perfusion

Predicted Behavioral Outcome Objective (s): The patient will have stable BPs and display no further
deterioration of deficits on the day of care.

Nursing Interventions Patient Responses

1. Assess for ICP 1. Drain 10 ml per hour

2. Compare BP cuff readings to art line readings 2. Values were close and comparable
3. Evaluate pupils 3. PERRL
4. Assess for inc. restlessness, irritability and the 4. Pt. rested and was calm
onset of seizure activity 5. On bedrest
5. Maintain bedrest 6. Pt. rested with eyes closed
6. Provide a quiet, relaxing environment 7. Order for Docusate prn, soft stools
7. Prevent straining with use of stool softeners 8. Tolerated, no seizure activity
8. Administer CCB, nimodipine (Nimotop) 9. Responds to voice and painful stimuli
9. Assess and monitor neurological status

Evaluation of outcome objectives:

Outcome was partially met. The patient showed no signs of deterioration in status, but the BPs were not stable.
The patients BP was 107/62 at start of shift and rose to 160/105 by end of shift. On admission the pts. BP was
261/132.

Problem # 4: Disturbed Sensory Perception

General Goal: Regain Sensory Perception

Predicted Behavioral Outcome Objective (s): The patient will maintain usual level of consciousness and
perceptual functioning on the day of care.

Nursing Interventions Patient Responses

1. Keep sensory stimulation to a minimum 1. Anxiety was reduced, and this prevented
2. Check grip strength confusion associated with sensory overload
3. Provide support 2. Weak bilateral hand grasps
4. Reorient patient to environment, staff and 3. Pt. was calm and quiet
condition 4. Reduced perceptual distortion of reality
5. Observe for behavioral responses like 5. Pt. was sedated, no agitation or combative
agitation and anxiety behavior
6. Have pt. follow commands 6. Opened eyes on command, wiggles toes, grasped
7. Assess LOC hands
8. Ordered Sedation: Propofol 7. UTA d/t sedation and ETT
8. Kept RASS from +1 to -1
Evaluation of outcome objectives:
Outcome was met. Was UTA LOC d/t ordered sedation but responded to voice and pain. Followed commands
such as open eyes, wiggle toes, and grab/unleash hands. There was no deterioration in neurological status
throughout shift.

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

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Problem # 5: Imbalanced Nutrition: Less Than Body Requirements
General Goal: Improve Nutritional Status

Predicted Behavioral Outcome Objective (s): The patient will maintain electrolytes WNL on the day of care.

Nursing Interventions Patient Responses

1. Daily weights 1. 236 lbs. on day of care (-4 from previous day)
2. Review Serum Electrolyte Values 2. Hyperchloremia & hyperglycemia
3. Review Serum albumin 3. 4.2 (WNL)
4. Assess NG tube placement 4. In place, secured
5. Administer pantoprazole 5. Tolerated
6. Strict I&O 6. 24 hr. Intake: 2190 ml; 24 hr. Output: 1935 ml
7. Monitor stool 7. Soft, brown
8. Auscultate Bowel Sounds 8. Bowel sounds present in all 4 quadrants

Evaluation of outcome objectives:

Outcome was partially met. All labs were within normal limits except Cl (110) and glucose (116).

Problem # 6: Anxiety
General Goal: No anxiety

Predicted Behavioral Outcome Objective (s): The patient will demonstrate reduced anxiety by remaining calm
and cooperative on day of care.

Nursing Interventions Patient Responses

1. Assess for s/s of anxiety 1. No “fighting or bucking” the ventilator

2. Reduce distracting stimuli 2. Resting enhanced in a quiet environment
3. Talk in a calm manner with an understanding 3. Helped establish a trusting relationship
attitude 4. Calmed down when hand was held
4. Provide support for client 5. Husband at bedside
5. Encourage visiting of family 6. Demonstrated understanding of situation by head
6. Reorient client to situation and need for nod when reoriented
mechanical ventilation 7. Maintained a RASS score of -1
7. IV Propofol

Evaluation of outcome objectives:

Outcome was met. Patient remained calm and cooperative. Never fought the ventilator or restraints. Did not
resist any care provided such as turning, suctioning and oral care.

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