Critical Care Concept Map Immanocompromised = kidney transplant in 2013 Key Problem /ND Impaired Gas Exehange ‘Supporting Data Ri. Bilateral effusions suggesting pulmonary edema or pneumonia Uncompensated respiratory acidosis on admission ABG’S: pH 6986, PCO2: 95.2 P02: 25.3 HCO3: 22.2 on admission $p02 93% on .50 FiO2 2 Key ProblemsND Ineffective Airway Clearance ‘Supporting Data: Expiratory wheezes Diminished breath sounds Brown secretions EIT [No cough noted Pronly responds to pain Key Problem/ND Impaired spontaneous ventilation Supporting Daa (On ventilator Mode: AC Rate: 14 Fi02: 50 TV: 400 PEEP: 5 $p02 93 Propofol 1V RR- 14 (no spontaneous Bumex 1V drip AN + , 4 | Key ProbiemND #6 | Key ProbleniND Decreased cardiac output Excess Fluid Volume Supporting Data: oe cH Reason For Needing HealthCare Seng De Celanegt (steal Dy surzen) elon ld Inte CCardiogenc vs septic shock Hgb: 1021 ‘Norepinephrine 1V Acute congestive hear flr, SUP carding gb: 102 Hee: 306 rest 5 ‘Weight:139 Ibs Enoxaparin SQ BUN: 29H BumerV Key assessments Cardiac & respiratory BU 20 Ck: 108 BP:105/55 Gamn:s0 Allergies: Neosporin or Tropoin 008 ee [BPrIST/77 MAP: 103 7 | Key ProblemiND #8 | Key Problem ND imbalanced Nusition Impaired vetbal communication ¥5 | Key ProblemND 5 EL Supporting Data Supporting Dat: Meee Te Calum: 6.8 L Inubated - Dna Albumin 2.3L Propofal 1V Support Des Total proten:4 8L Open eyes to pain and some Moning OI ee Potassium: 3.3L verbal command Norepinp Pamtoprazole IV Doesn't follow simple GERD commands Expiatory wheezes ERD Excess uid volume ta Cardia arrest Bumex 1V CHE —pr sannister COncepT Mapping: A Critical Thinking Approach, Davis, 2002,Problem #__1_: Impaired Gas Exchange Genetal Goal: Inereased Gas Exchange Predicted Behavioral Outcome Objective (3): The patient will have SpO2 greater then 94% and have ABG'S WNL on the day of ea ‘Nursing Interventions Patient Responses 1, Elevate HOB 30 degrees 1. RR- 14 Sp02- 93-97% 2. Suetion secretions 2. Minimal brown secretions 3. Assess breath sounds 3. Expiratory wheezes 4. Assess ABG'S 4, On day of eare- pH-7.40 PCO2- 38 PO2-67.6 HCO3-23.1 5. Assess SpO2 6. Assess chest x-ray 5. Sp02- 93-97% 7. Assess BP & HR, 6. BP- 155/77 HR-87.95 8. Assess P/F ration 7. PIR: 135.2 Evaluation of outcome objectives: Paially met, Patients SpO2 was 93% at 1100, ABG'S were WNL. (pH 7.40 PCO2-38 PO2-67.6 HCO3-23.1) Problem #2. General Goa Ineffective Airway Clearance Predicted Behavioral Outcome Objective (6): The patent will have lear breath sounds on the day oF care. ‘Nursing interventions Patient Responses 1. Assess breath sounds 1. Expiratory wheezes 2. Assess secretions 2. Minimal brown secretions 3. Elevate HOB 30 degrees 3. RR-14 Sp02 93.97% 4. Hyper-oxygenate & suction pm 4, Minimal brown secretions 5. Tum Q2H 5. RR- 14 SpO2 ~ 93-97% 6. Monitor WBC 6. WBC- 8.1 7. Administer corticosteroid 7. Prednisone Smg given 8. Monitor RR 8.14 Evaluation of outcome objectives: Not met. Patient had expiraiony wheeze P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002,Problem # _3___: Impaired Spontaneous Ventilation Genetal Goal: Maintain Ventilations Predicted Behavioral Outcome Objective (3): The patient will oleate ventilator settings evidenced by no alarms and have moist mucous membranes onthe day’ of care ‘Nursing lotervenions Patient Responses 1. Assess ventilator settings 1, Mode- AC Rate- 14 Fi02- 50 TV-400 Peeps 5 2. Monitor SpO2 2. SpO2- 93.97% 3. Suction pm 3. Minimal brown secretions 4. Mouth care Q4H & pen 4. Moist mucous membranes 5. Assess correct ETT placement 5.24 at lip 6. Elevate HOB 30 degrees 6. RR- 14 SpO2- 93-97% 7. Assess Pts ability to cooperate on vent 7. No alarms went off, didn’t fight vent 8. Assess secretions 8. Minimal brown secretions Evaluation of outcome objectives: Met Patient tolerated ventilator as evidenced by no alarms going off ‘Macous membranes were pink and moist, Problem #_4__: Decreased Cardiac Output General Goal: Maintain Adequate Cardiae Output Predicted Behavioral Outcome Objective (5): The patient will have maintain a MAP greater than 65 on the day of care ‘Nursing interventions Patent Responses 1. Assess vital signs 1, HR-87.95 RR-14 BP 105/55 ~ 157/77 MAP 71-103 Sp02-93-97 Temp 99.9 2, Assess capillary refill 2. Less than 3 seconds 3. Administer diuretics 3. Bumex Iv given 4, Monitor ECG 4, NSR with a PAC 5. Monitor troponin & platelets 5. Troponin- 0.04 platelets- 172 6. Administer antiplatelets 6, Enoxaparin 40mg SQ 7. Apply SCD 7. No signs of DV: no edema, redness or warmth 8. Bedrest 8. On bedrest and sedated - Propofol Evaluation of outcome objectives: Met, Patient's MAP was between 71-100 on day of care COCCI IRIE PPPOE ETS, ZOU ae ee EeProblem # 6 _: Excess Fluid Volume General Goal: Balanced fluid volume Predicted Behavioral Outcome Objective (6): The patient will maintain urine output of 30m! an hour, balanced VO, and normal values on day of care ‘Nursing Interventions Patient Responses 1. Monitor hourly UO Weigh . Assess breath sounds |. Monitor BP & CVP Assess H/H. Assess urine color . Assess fluid balance (+ or -) .. Assess renal function BUN Creatinine 1. 0700- 2Sec 0800-200 0900-200 1000- 325 1100-225 2. 139s (last weight was 140bs) 3. Expiratory wheezes 4, BP- 116/66 CVP-10 5. Hbg-10.2 L Het- 30.6% L 6. Yellow & clear 7.496 8. BUN - 29 H Creatinine- 1.0 Evaluation of eutcome objectives: Not met. Patient's urine output for 0700 was 2Sml, her 10 was “96 and: hher HH were both low(hbg-10.2 Het-30,6%%) and her BUN was high (BUN 29), Problem #_7__: Imbalaneed Nutritional General Goal: Improved nutritional status Predicted Behavioral Outcome Objective (s): The patient's albumin level wil be in normal range of 25-52 on day of care NNarsing Interventions Patient Responses 1. Assess bowel sounds 2. Administer calcium gluconate 3. Assess residual 4, Monitor labs 5. Elevate HOB 30 degrees 6. Administer PPI 7. Assess stool color and consistency 8. weigh 1. Active in all quadrants 2. Caleium gluconate IV (Ca- 6.8L) 330ml 4. Albumin- 2. 6.8L 5. RR- 14 SpO2 - 93-97% 6. Pantoprazole 40mg IV 7. No bowel movements on day of care 8.139 Ibs .3L. protein- 4.8L calcium- Evaluation of outcome objectives: Not met Patient's albumin (2.3), protein (4.8) and caleiam (6.8) were all lowProblem # 8 _: Impaired Verbal Communication General Goal Effective Communication Predicted Behavioral Outcome Objective (5): The patient wil respond with non-verbal behaviors on the day ofeare, [ Narsing imerventions Patient Responses 1. Assess neuro status 1. Sedated, responds to pain(eyes open) 2. Assess ETT tube 2.24 at lip 3. administer sedation 3. Propofol Iv 4, Use comfort touch 4. Does not respond to touch 5. Assess ability to follow 5. Does not follow simple commands verbal commands 6, Assess LOC 6, Responds to pain (eyes open) 7. Assess GCS 7.GCS-2T 8. Assess RASS score 8. RASS- Evaluation of outcome objectives: Met. Patient opened eyes to pai Problem #3: Ineffective Tissue Perfusion General Goal: Improved tissue perfusion Predicted Behavioral Outcome Objective (s)- The patent will have capilary refill ess than 3 seconds on the day of care ‘Nursing Interventions Patient Responses 1, Monitor VS 1. HR- 87-95 RR-14 BP 105/55 -157/77 MAP- 71-103 SpO2-93-97 Temp- 99.9 2. Elevate HOB 30 degrees 2. RR- 14 SpO2 - 93-97% 3. Assess CK and troponin 3. Troponin- 0.04 CK- 105 CK MB- 5.0 4, Assess ECG 4. NSR with a PAC 5. Tum Q2H 5. RR- 14 Sp02~ 93.97% 6, Monitor Sp02 6, Sp02~ 93-97% 7. Assess pain 7. CPOT- 0 sedated 8. Assess capillary refill 8. Less than 3 seconds Evaluation of outcome objectives: Met Patient's capillary refill was less than 3 seonds,