Assessment and Concept Map Care Plan for Critical Care Patient Created by KayLynn Rounds Nursing Student ‘Youngstown State University P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.ey Problet Impaired Gas Exchange sip: Raise HOB Chest physiotherapy AIC vent Hypoxemia PEEP 10 ABG’S Propofol 35mg, Excessive thick white secretions ‘Trach 8mm. Reason for Needing Health Care Key Problem i Dw/Surgery) Risk for Impaired Skin Integrity a found unconscious inthe field. Due Impaired Physical ‘to gun shots in the cranium. Patient Intubated while in field. Craniotomy upon, admission to SICU. a 24 yo female, Full Code, NKA Ineffective tissue perfusion [Impaired skin integrity Loc Bed Rest A 4 + 1 sided cranial wound See eae Le Risk for Infection Key Problem Risk for Aspiration Ineffective tissue perfusion Sedation Poor nutrition Key Problem Risk for Ineffective Breathing Pattern SD: Urine analysis /cuture & -—J} sensitivity Ineffective tissue perfusion SD: Ventilator rate 14 ‘Thick white secretions 7} Patent is sedated oor nutrition | Inactive Decreased LOC | Prepoft L sided cranial wound Trach Pain ‘Increased ICP Sedated Patient Respiratory Rate 14 GCS 10 Nonsterile intubation P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.: Ineffective Airway Clearance General Goal: Effective Airway Clearance Re Predicted Behavioral Outcome Objective (s): The patient will... ventilator settings without having any issues...on the day of care ‘Nursing Interventions Patient Responses 1. Suction PRN 1. Coughing, no gag 2. Q2 tums 2. Patient occasionally moved on her 3. Assess breath sounds ‘own but maintained position most of 4. Assess mouth and nose the time. 5. Maintain HOB elevated 30 3. Diminished clear breath sounds degrees 4. No signs of occlusion 6. Monitor oxygenation status 5. HOB elevated, tolerated well 6. SpO2 maintained in normal limits. Evaluation of outcome objectives: Outcome met. Patient maintained ventilator settings and was stable during my shift. Problem #2 _; Impaired gas exchange General Goal: Improved gas exchange Predicted Behavioral Outcome Objective (s): The patient will... maintain an SpO2 greater than 95% and ABG’s within or close to normal limits...on day of care ‘Nursing Interventions Patient Responses 1. Continuous monitor of SpO2 1, Sp02 maintained >95% 2. Monitor ABG’s 2. ABG’s improving since admission 3. Keep HOB elevated 30-45 degrees 3. HOB elevated 4, Assess for diaphragmatic breathing 4. Pt. wasn’t using accessory muscles Evaluation of outcome objectives: Outcome met. Patient maintained SpO2 > 95% and ABG’s are near normal more than before. P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.Problem # 3 ___: Risk for Aspiration General Goal: Free of aspiration Predicted Behavioral Outcome Objective (s): The patient will... be able to avoid aspiration and pneumonia... on the day of care. ‘Nursing Interventions Patient Responses 1. Assess trach placement 1. Trach midline 2. Suction PRN 2. Cough, no gag 3. HOB elevated 30-45 degrees 3. HOB elevated 4. Assess cough and gag reflex 4, Cough present, no gag 5. Medication 5. Patient receiving UNASYN Evaluation of outcome objectives: Outcome met. Patient didn’t aspirate during my shift. Problem #_4__; Risk for Ineffective Breathing Pattern General Goal: Allow the patient to have slow and controlled breaths Predicted Behavioral Outcome Objective (s): ‘The patient will... Maintain a slow and controlled breathing pattern...on day of care. ‘Nursing Interventions Patient Responses 1. Co nuous monitor of SpO2 1. SpO2 maintained >95% 2. Monitor ABG’s 2. ABG’s improving since admission 3. Keep HOB elevated 30-45 degrees 3. HOB elevated 4. Assess for diaphragmatic breathing 4. Pt. wasn’t using accessory muscles 5. Assess pain/anxiety 5. Patient on pain/anxiety meds Evaluation of outcome objectives: Outcome met. Patient maintained normal breaths while on the ventilator with minimal signs of anxiety. P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.Problem # _5__: Risk for Infection General Goal: Keep pt. free from infection. Predicted Behavioral Outcome Objective (8): The patient will... remain free of signs and symptoms of infection on the day of care. Nursing interventions 1. Assess trach 1. Trach clean and in place 2. Suction PRN 2. Cough, no gag 3. HOB clevated 30-45 degrees 3. Dec. lung secretions 4, PIN 4, Nutrition through PEG 5. Medication 5. Tolerating medication 6. Chest physiotherapy 6. Pt’s lungs remain clear Evaluation of outcome objectives: Outcome met patient remained free of bacteria and infection during my shift Problem #6: Risk for Impaired Skin Integrity General Goal: Keep my patient free from skin breakdown. Predicted Behavioral Outcome Objective (s): ‘The patient will... remain free of skin breakdowns...on day of care. ‘Nursing Interventions Patient Responses 1. 2QH tums 1, No redness or breakdowns 2. Skin Assessment 2. Pt. shows no signs of breakdown or redness 3. assess nutritional status 3. Pt. receiving continuous tube feed 4. 1V fluids 4. Hydration being maintained Evaluation of outcome objectives: Outcome met. Patients skin remained intact and free from redness / breakdown during my day of care. P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.Problem #_7__: Impaired Physical Mobility General Goal: Improve physical mobility Predicted Behavioral Outcome Objective (5): The patient will...do ROM exercises with the me to decrease atrophy on the day of care. ‘Nursing Interventions Patient Responses 1. Pain Assessment 1. CPOT scaled = not aggravated or anxious 2. IV fluids 2. Hydration being maintained 3. HOB elevated 30-45 degrees 3. easy respirations 4. Nasal cannula 4, ine. oxygenation so pt. isn’t out of 5. Anxiety medication breath. 5. Pt. tolerated Evaluation of outcome objectives: Outcome not met. Tried getting patient to help with ROM exercises. Pt. too sedated and worn out to help. Student nurses picked up extremities and did as much as possible until resistance was met on day of care. P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.