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Critical Care Patient Concept Map Care Plan #3 Key Problem/ND

Risk for infection
#1 Key Problems/ND
Key Problem/ND #2 Ineffective airway clearance Supporting Data:
Impaired Gas Exchange Foley catheter in place
Supporting Data: Vancocin (vancomycin) IV
Supporting Data: Inspiratory Wheeze, Rhonchi Cefepime (cephalosporin) IV
Pulmonary contusion, MVA bilaterally WBCs increased
Vent – PSV mode Tan, Thick secretions Neutrophils increased
FiO2 .40 ETT requires suctioning Q2h Proventil (albuterol) Inhalation
ABG’s pH 7.40, PC02 29.3, P02 76.5, Mouth care Q2h Turn Q2h
HC03 20.0 Mechanical ventilation to help A-line Right femoral artery
Compensated Respiratory Alkalosis with breathing and maintaining CVC Triple Lumen
Had accident and was unconscious but patency of airway. Malnutrition
didn’t need mechanical ventilatory
support until in the SICU on 9-22-21.

#4 Key Problem/ND:
#5 Key Problem/ND
Imbalanced nutrition: less than
Risk for electrolyte imbalance
body requirements

Reason For Needing Health Care Supporting Data:

Supporting Data:
(Medical Dx/ Surgery) Furosemide (loop diuretic)
Hx GERD
Hypernatremia (Na – 157)
ETT
MVA – polytrauma, subdural hematoma Hyperchloremia (Cl – 127)
Inability to ingest foods
83-year-old, male, DNR-CCA Edema/excessive fluid volume
Psychological factors
Chronic kidney disease
Tube feed
Total protein decreased (5.3) Key Assessments:
Hyperglycemia VS with a focus specifically on respiratory
with mechanical ventilation and labs
involving kidney function.

Allergies: Codeine, Lyrica

#6 Key Problem/ND #7 Key Problem/ND #8 Key Problem/ND

Fluid volume excess Risk for impaired skin Risk for Constipation
integrity/DVT
Supporting Data: Subjective Data:
Edema of face and arms Subjective Data: Bedrest
Increased Na – 157 ETT Sennosides once/day
Chronic Kidney Disease Bed rest/immobility Polyethylene Glycol once/day
Creatinine - 2.8 Lovenox once/day No stool since admitted to
BUN - 63 SCD’s hospital on 9-20-21 to 9-23-21
Hemoglobin – 7.0 Ted hose
Hematocrit – 22.1 Heel protectors
RBC’s – 2.30
Platelets – 112
GFR – 26

Step 3: Draw lines between related problems. Number boxes as you prioritize problems.

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

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LASTLY- label the problem with a nursing diagnosis.

Step 4: Identification of goals, outcomes, and interventions.
Step 5: Evaluation of Outcomes
Problem # 1: Impaired Gas Exchange
General Goal: Always maintain gas exchange.

Predicted Behavioral Outcome Objective (s): The patient will……always maintain gas exchange on the day
of care.

Nursing Interventions
1. Monitor RR rate, depth, and ease of RR. 6. Position patient with HOB 30-45
2. Auscultate breath sounds Q 1 to 2 degrees
hours. 7. Encourage coughing
3. Monitor for restlessness, agitation, and 8. Suction patient PRN
confusion.
4. Monitor 02 saturation with pulse ox
5. Observe for cyanosis of skin

Patient Responses
1. Patient will have normal RR and have no signs of respiratory distress
2. Patient will not exhibit any adventitious sounds in lungs on auscultation.
3. Patient will not have a new onset of agitation, confusion, and restlessness.
4. 02 saturation will stay above 92%
5. Patients skin color will remain appropriate with ethnicity
6. Patients’ airway will remain open and clear with elevation of HOB
7. Patient will keep airway clear by coughing while suctioned
8. Patient will keep airway clear when suctioned PRN

Evaluation of outcome objectives: Patient will always maintain gas exchange with help of the interventions
above.

Problem # 2: Ineffective airway clearance

General Goal: Patient’s airway will remain clear
Predicted Behavioral Outcome Objective (s): The patient will……always have a clear airway on the day of
care.

Nursing interventions
1. Auscultate breath sounds Q 1-2 hours
2. Monitor respiratory patterns, rate, depth, and effort.
3. Monitor blood gases.
4. Position HOB 30-45 degrees
5.Administer bronchodilators
6. Turn with use of bed – 40 degree turns
7. hyper oxygenate before suctioning
8. suction less than 15 seconds

Patients’ response
1. Patients’ breath sounds will remain free of adventitious sounds.
2. Patient’s respiratory pattern will remain normal.
3. Blood gases will continue to improve and will show no sign of decline.
4. Patient will be able to maintain airway better with HOB elevated.
5. Bronchodilators will help the patient’s airway remain clear and open.

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

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6. Turning the patient with the use of an automatic bed will help an immobilized patient decrease risk
of pulmonary complications.
7. Hyper oxygenating will prevent desaturation.
8. Patient will not have a drop in partial pressure due to suctioning.

Evaluation of outcome objectives: Patient will have an effective airway clearance with help of the
interventions above done by the nurse.

Problem # 3: Risk for infection

General Goal: Prevent patient from developing an infection with preventative measures taken.

Predicted Behavioral Outcome Objective (s): The patient will…… remain free from infection for at least 2
whole shifts.

Nursing Interventions
1. Wash hands before and after care 7. Assess lung sounds for adventitious
2. Ensure lines are handled aseptically sounds.
and should be assessed Q shift 8. Always follow standard precautions
3. Observe and report signs of infection:
such as redness, tenderness, warmth,
and fever.
4. Assess temperature and VS of patient
hourly.
5. Monitor lab values (WBC’s)
6. Foley care to be done Q shift

Patient Responses 6. Foley will remain free from infection

1. Patient will remain protected from with proper foley care and monitoring.
infection 7. Patient’s lungs will remain clear and
2. If issue with line it will be addressed, shows no sound of infection.
and patient will remain free of any harm 8. With use of standard precautions nurse
from it. Nurse will keep the line free will avoid spreading any source of
from exposure of infection. infection to the patient and themselves.
3. Patient will remain free of any signs of
infection.
4. Patient’s VS will remain within normal
range.
5. Patient’s lab value will remain in
normal range.

Evaluation of outcome objectives: Patient will remain free of infection for at least 2 whole shifts by using all the
following interventions above.

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

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Problem #4: Imbalanced nutrition: Less than Body Requirements

General Goal: Maintain/help to fix nutrition imbalance

Predicted Behavioral Outcome Objective (s): The patient will……get adequate nourishment on the day of
care.

Nursing Interventions
1. Monitor the patients labs like albumin and prealbumin
2. recognize and observe for signs of malnutrition
3. Get patient hooked up to tube while maintaining HOB at 30-45 degrees at all time
4. Consider administering Vitamin D, to help heal fractures.
5. Monitor state of oral cavity
6. Check for gastric residual
7. Monitor blood sugar

Patient Responses
1. Patients’ labs will stay in normal range.
2. Patient will not show any signs of malnutrition
3. Patient will always get nutrients through tube feed.
4. Vitamin D will be used to help the patient heal post-accident.
5. Oral cavity will remain intact and free from injury.
6. Gastric residual will be checked before medication is administered.
7. Blood sugar will remain in a normal range

Evaluation of outcome objectives: Patient will remain free of malnutrition and the prior nutrition issues will
be resolved with help of the interventions above.

Problem # 5: Risk for electrolyte imbalances

General Goal: Maintain electrolytes within normal range

Predicted Behavioral Outcome Objective (s): The patient will…… have a decrease in edema, maintain
electrolytes levels, and maintain a normal serum pH on the day of care.

Nursing Interventions
1. Monitor VS hourly. 5. Review electrolyte labs
2. Monitor cardiac rate and rhythm 6. Monitor effects of diuretics
3. Daily weights 7. Administer fluids as needed.
4. Monitor neurological changes. 8. Monitor I/O’s

Patient’s response
1. VS will remain in normal range with no indications of electrolyte disturbances.
2. Cardiac rhythm will remain normal.
3. Weight will remain around the same weight – will not show large increase or decrease.
4. Neurological status will remain at their base level (their normal)
5. Electrolytes will remain within normal range with blood draws.
6. The diuretics will continue to be used if no electrolytes abnormalities occur.
7. Fluids will be given if it can establish normal electrolyte levels (hypertonic, hypotonic, isotonic –
depends on what they’re lacking)
8. I/O’s will remain consistent with each other.

Evaluation of outcome objectives: Patient will remain free of electrolyte disturbances and be monitored daily
for any fluctuations.

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

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Problem # 6: Fluid Volume Excess

General Goal: Remain free of fluid volume excess.

Predicted Behavioral Outcome Objective (s): The patient will……remain free of edema, maintain clear lungs
sounds, remain free of JVD, maintain VS’s on the day of care.

Nursing interventions
1. Monitor location and extent of edema. 1.
2. Monitor daily weight.
3. Monitor I/O’s
4. Monitor VS’s
5. Auscultate lung sounds
6. Assess for JVD – HOB 30-45 degrees
7. Monitor kidney function
8. Administered ordered diuretic

Patient Responses
1. Patients’ edema will be monitored for worsening and the degree.
2. Patients’ weight will not fluctuate
3. Patients’ I/O’s will be consistent with each other.
4. VS’s will remain stable and in normal range.
5. Lung sounds will show no sign of crackles.
6. No JVD will be present.
7. Kidney function will remain stable.
8. Diuretic will help pull some of the fluids off and decrease edema.

Evaluation of outcome objectives: Patient will remain free of edema, maintain clear lungs, remain free of
JVD, and maintain VS’s.

Problem # 7: Risk for impaired skin integrity/DVT

General Goal: Remain free of anything that causes skin integrity and clots.

Predicted Behavioral Outcome Objective (s): The patient will……show no sign of impaired skin integrity and
remain free from any signs of DVT’s on the day of care.

Nursing interventions
1. Inspect and monitor skin conditions once a shift.
2. Turn patient Q2h
3. Use pillows to prevent bony prominences from rubbing.
4. Heel protectors
5. SCD’s
6. Ted hose
7. Monitor mouth and reposition ETT
8. Administer Lovenox once/daily

Patient responses
1. Skin will remain free from signs and indications of pressure ulcers or impairments.
2. Patient will alleviate pressure off each side every 2 hours.
3. Pillows will keep pressure off bony prominences preventing impaired skin integrity.
4. Heel protectors will protect patients’ bony heels from developing sores/ulcers.
5. Prevention of clots while immobilized
6. Prevent and keep patient free from clots

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

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7. Patient will remain free from impaired skin integrity and trauma related to ETT
8. Lovenox will help prevent clot formation while a patient is immobilized.

Evaluation of outcome objectives: Patient will continue to have good skin integrity and be free from any
DVT’s/clots.

Problem # 8: Risk for Constipation

General Goal: Get the patient’s bowels moving.

Predicted Behavioral Outcome Objective (s): The patient will……develop active bowel sounds and have a
BM on the day of care.
Nursing interventions
1. Administer stool softener and/or laxatives
2. Assess normal pattern of bowel movements
3. Monitor for abdominal distention
4. Assess bowel sounds
5. Review medications patient is on
6. Check for impaction
7. Turn and position in bed frequently to help mobilize the bowel.
8. Administer suppositories or enema if not able to achieve BM.

Patient responses
1. Patient will develop active bowel sounds and have BM.
2. Patient will explain normal bowel pattern
3. Patient will not have any abdominal distention
4. Patients’ bowel sounds will be active
5. Medications like narcotics make constipation worse.
6. Patient will not have any impacted bowel.
7. Patient’s bowels will start moving as the get mobilized as best as they can when on bedrest.
8. This will help the patient achieve a BM if they are not able to on their own.

Evaluation of outcome objectives: Patient will achieve a BM and/or develop active bowel sounds within the
shift.

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