1

Problem #1 Impaired gas

exchange
 Adventitious breath
sounds
 Decreased SpO2
levels
 Changes ABGs
 pH 7.43, PCO2 44.8,
PO2 76.5, HCO3 29.3
 FiO2 50%
Problem #7 Risk for
Problem #8 Risk for Disuse ineffective tissue perfusion
Syndrome  Intubated
 Immobility
 Intubated  Obesity
 Altered LOC  Restraints
 Restraints  Venous stasis
 Trouble keeping head up  1 + Edema
 Decreased strength in  Turning q2h
lower extremities

Problem #6
Problem #2 Ineffective Constipation
airway clearance  Positional
Reason For Needing Health Care restrictions
 Diminished lung  Immobility
sounds in both right Acute Respiratory Distress  Inadequate fluid
and left lungs or dietary intake
Syndrome w/ Hypoxia
 Ipratropium  Polyethylene
 Albuterol glycol
 Turn q2h Key Assessment:  Sennosides-
 Suctioning q2h PRN  Listen to breath sounds docusate sodium
 Orthopnea  Monitor SpO2  Unfamiliar place
 Monitor ABGs (hospital)
 Monitor Respirations
 Monitor PaO2
 Monitor LOC Problem #5 Risk for
 Monitor for cyanosis
developing DVTs/PE/Clots
Problem #3 Anxiety  Monitor chest X-Rays
 Intubated
 Bedrest
 Being on a ventilator  Immobility
 ETT tube  Turning q2h
 Restraints  Frequent position changes
 ICU room with no windows  Enoxaparin
 Extended hospital stay  Restraints
 Increased HR
 Increased BP
 Screaming pt. across hall Problem #4 Impaired verbal
communication
 Intubated
 Assess cuff pressure
 Sedated
o Versed
o Fentanyl
 Opens eyes spontaneously
 Uses hand jesters when
possible

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

 2

Problem # 1: Impaired gas exchange

General Goal: increased gas exchange

Predicted Behavioral Outcome Objective (s): The patients ABGs will be within
normal limits, and will tolerate weening from ventilator on day of care.

Nursing Interventions Patient Responses

1. Assess breath sounds 1. Diminished breath sounds both R & L lung
2. Assess ABGs 2. ABGs are not within normal limits, metabolic alkalosis
3. Elevate HOB 30 degrees 3. Pt tolerates change well
4. Monitor SpO2 4. SpO2 was between 92-94 on vent
5. Monitor LOC 5. Pt was alert during shift. Hand gestures, opened eyes

Evaluation of outcomes objectives: Pt’s SpO2 stayed between 92-94 on vent. When
extubated SpO2 dropped to 82 and bounced back up to 94. Pt. tolerated HOB increases,
position changes.

Problem # 2 ineffective airway clearance

General Goal : increased airway clearance
.
Predicted Behavioral Outcome Objective (s): The patient will have increased
bilateral breath sounds on day of care.

Nursing Interventions Patient Responses

1. Assess breath sounds 1. Diminished breath sounds on R & L lung

2. Suction q2h 2. Brown/green secretions removed
3. Administer albuterol 3. Helped open lungs
4. Administer ipratropium 4. Helped open lungs
5. turn q2h 5. Pt tolerated turning

Evaluation of outcomes objectives: secretions removed with each suctioning, breath sounds
stay diminished, albuterol/ipratropium helped open lungs, tolerated turns well.
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis
 Problem # 3 : Anxiety
General Goal: Decrease anxiety 3

Predicted Behavioral Outcome Objective (s): The patient will have decreased
anxiety with vitals and body language to match on day of care.

.
Nursing Interventions Patient Responses

1. Maintain a calm manner when

With pt. 1. Pt. seems relaxed and listens when spoken to
2. Play music for the pt. 2. Pt has music playing and seems relaxed
3. Talk to pt. whenever in room 3. Pt seems relaxed and listens when spoken to
4. Explain procedures to pt 4. Helped pt know what to expect ex: pinch w/
5. Provide reassurance injection
5.pt calmed down when anxious when comforted

Evaluation of outcomes objectives: Pt. was comforted when signs of anxiety arose
(increased HR, increased BP, thrashing)

Problem # 4 impaired verbal communication

General Goal: effective communication

Predicted Behavioral Outcome Objective (s): The patient will respond with
appropriate behaviors to verbal commands on day of care

Nursing Interventions Patient Responses

1. Learn pts needs and pay

attention to nonverbal cues 1. Pt. uses hands when possible
2.Place important objects close 2. Maximize pt independence
3. never speak as though they do
not comprehend 3. Explaining procedure pt nods
4. keep fentanyl and versed titrated 4. Do not over sedate pt

Evaluation of outcomes objectives: Pt communicated as best as possible using hand gestures

and nods when on ventilator.

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

 Problem # 5 risk for DVTS/PE/Clots
4
General Goal: remain free from DVTs/PE/Clots

Predicted Behavioral Outcome Objective (s): The patient will remain free from
DVTs/PE/Clots on day of care

Nursing Interventions Patient Responses

1. Administer enoxaparin 1. Pt nodded when told why he was getting shot

2. turn q2h 2. Pt tolerated turning well
3. ROM exercises when
prompted on lower extremities 3.needed assistance with moving L.E

4. Frequent position changes 4. Pt tolerated position changes well

5. teach to not cross legs 5. Pt understood to not cross legs (nodded)

Evaluation of outcomes objectives: pt. remained free from DVTs/PE/clots, Nodded in

understanding when procedures and teachings were said.

Problem # 6 Constipation
General Goal: pt will be free from constipation

Predicted Behavioral Outcome Objective (s): Pt will have a bowel movement on

day of care
Nursing Interventions Patient Responses

1. Moving extremities
with assistance (exercise) 1. Pt tolerated movement of lower extremities

2. Stool softner (docusate) 2. Pt took medication with no adverse effects

3. polyethylene glycol 3. Pt took medication with no adverse effects

4. 4. Position changes 4. Pt tolerated position changes well

Evaluation of outcomes objectives: pt did not pass stool during shift. Medications were
given and tolerated. Position changes were made and tolerated. Worked on moving lower
extremities for exercise.

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

 Problem # 7 Risk for ineffective tissue perfusion
General Goal: effective tissue perfusion 5

Predicted Behavioral Outcome Objective (s): the pt will have adequate tissue
perfusion on day of care.

Nursing Interventions Patient Responses

1.Administer IV fluids as ordered 1. Pt tolerated fluids. Maintains adequate filling

1 pressure and optimizes CO needed for perfusion
2. antihypertensives 2. Reduces systemic resistance, optimizes CO
Increases perfusion.
3.Check restraints 3. Restraints not too tight
4. +1 edema.. administered Lasix 4. Pt urinary output was increased. Gets fluid off,
a5. Position changes allows for better perfusion
5. pt tolerated position changes well

Evaluation of outcomes objectives: pt. tolerated IV fluids, Lasix & antihypertensives well.
Restraints were not too tight allowing good blood flow. Frequent position changes to help
promote tissue perfusion and blood flow.

Problem # 8 risk for disuse syndrome

General Goal: increase use of extremities

Predicted Behavioral Outcome Objective (s): The pt will remain use limbs as
much as possible to help stay free from disuse syndrome on day of care

Nursing Interventions Patient Responses

1. Make sure arm restraints 1. Able to fit two fingers between arm restraint
are not too tight
2. Move legs/feet/toes 2. Assistance needed but pt tolerated well
3. Pillows to help support neck 3.pt did not tolerate holding neck up. Pillows helped
4. decreased strength lower extremities 4. Assistance needed in moving, but pt did well
5. Try to maintain LOC, encourage
engagement 5. Pt LOC was good, he was able to work on moving LE.

Evaluation of outcomes objectives: pt was able to work on lower extremity movement when
on vent. Worked on upper extremity movement once off and restraints were removed.

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