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Complex Care Concept Map

Mitzie Martin

Youngstown State University, Centofanti School of Nursing

Complex Care Lab

Melanie Bakes

4/6/24
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#2 Key Problems/ND
Ineffective Airway Clearance
#4 Key Problem/ND Supporting Data: #3 Key Problem/ND
Impaired Skin Integrity - CTA pulmonary: Impaired body defense
Supporting Data: subsegmental atelectasis in mechanisms
- Coccyx wound. posterior and lower lobe Supporting Data:
- Surgical incision on posterior sections - Immobility
neck. - Diminished lung sounds - Sepsis
- Decreased LOC bilaterally on auscultation. - Wounds
- Decreased cardiac output. - Unable to breathe - RBC: 2.91
- Sepsis independently d/t CVA and - Hgb: 8.4
- Type 2 diabetic arrest. - Hct: 25.5
- Immobility - Weak cough with - WBC: 18.3
- Edema suctioning. - Neutrophils: 83
Treatment: Treatment: - Lymphocytes: 11
- Daily dressing changes - Mechanical Ventilation, Medication/Treatment:
Medical History: ETT: rate of 12, FiO2 60%, - Zosyn 3,375mg q 8hr
- Resection of intradural C7 TV 400, PEEP 6. - Vancomycin 2000mg
tumor - Oral care with
chlorhexidine q 4hr

#1 Key Problem/ND:
#5 Key Problem/ND
Decreased Cardiac Output
Altered Consciousness
Supporting Data:
Reason For Needing Health Care Supporting Data:
- Hypotension, BP of 99/53.
Septic Shock - Sustained a CVA
- ECG sinus bradycardia
Key Assessments: - CT head: loss of grey-
with PACs.
- Vital signs white differentiation along
- Heart rate in the 40s.
- Lab values R cerebral hemisphere
- Bilateral pedal and post
- Oxygenation and ventilation - GCS score of 7
tibial pulses of 1+.
- Intake and output - Only responds and opens
- CK of 502, 1,706 on
- Nutritional status eyes to pain.
admission.
- Skin integrity - Pupillary response
- Troponin of 47, 127 on
- Signs and symptoms of infection sluggish.
admission.
- Cardiovascular Assessment - Does not follow
- Lactate of 2.9
- Pulses and capillary refill commands.
Medication/Treatment:
Medication/Treatment:
- Levophed at 3mcg/min.
- Intubated and sedated with
- Epi and adenosine at
fentanyl at 50mcg/hr.
bedside.
-
- Arterial line

#7 Key Problem/ND
#6 Key Problem/ND Risk for Imbalanced Nutrition
Risk for Imbalanced Fluid Supporting Data: #8 Key Problem/ND
Volume - Immobility Powerlessness
Supporting Data: - Mechanical Ventilation Supporting Data:
- Decreased CO, which - Sedation with fentanyl - Sustained a CVA and
can lead to poor - Only responsive to pain arrest.
perfusion to kidneys. - Nothing by mouth. - Immobility
- Non-pitting edema of - Albumin 2.7 - Sedation with fentanyl
bilateral upper Medication/Treatment: - Mechanical ventilation
extremities. - Protonix 40mg IV daily - Altered consciousness.
- Creatinine of 2.3 - Oral gastric tube - Only responsive to
- Albumin of 2.7 - Standard with fiber tube pain.
Treatment: feed running at - Unable to
- Foley catheter for I&O 40mL/hr. communicate.
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Problem #1: Decreased Cardiac Output

General Goal: Increase cardiac output.
Predicted Behavioral Outcome Objective (s): The patient will demonstrate adequate cardiac output
as evidenced by maintaining blood pressure above 90/50 and pulse rate greater than 40bpm, palpable
pulses, and capillary refill less than 3 seconds on day of care.
Nursing Interventions Patient Responses
1. Administer and titrate levophed as 1. Pt’s blood pressure is increased and
ordered. maintained within parameters.
2. Place on cardiac monitor with alarm 2. Pt remained within parameters, able to
parameters. monitor for any changes.
3. Perform cardiac assessment q 4hr and 3. S1 and S2 heard, no extra heart sounds.
PRN. 4. Pt had no significant lab values/changes.
4. Monitor lab values. 5. Radial pulses 2+, pedal 1+, cap refill less
5. Assess bilateral pulses and cap refill. than 3 seconds.
6. Assess oxygen saturation. 6. Pt’s O2 remained above 93%.
7. Monitor urinary output q 1hr. 7. Maintained at least 30mL per hour.
8. Assess for edema, skin temp, and color. 8. Nonpitting edema BUE, skin warm and
dry.
Evaluation of outcome objectives: Patient met outcome objectives. Blood pressure and pulse
remained within patients’ parameters. Pulses remained palpable and cap refill WDL. No worsening
signs of decreased CO.

Problem #2: Ineffective Airway Clearance

General Goal: Maintain adequate oxygenation and patent airway.

Predicted Behavioral Outcome Objective (s): The patient will maintain an oxygen saturation above
93% and maintain a patent airway during day of care.

Nursing Interventions Patient Responses

1. Place on continuous pulse oximeter 1. Pt’s O2 sat remained above 93%.
2. Perform respiratory assessment q 4 hrs. 2. Lung sounds diminished bilaterally
3. Assess ETT placement and securement 3. ETT at correct lip line.
4. Suction patient q 2 hour and as needed. 4. Airway remained free of secretions.
5. Elevate head of bed. 5. Promotes optimal lung ventilation.
6. Administer 100% O2 during suctioning. 6. Prevented pt’s O2 sat from dropping
7. Monitor for ventilator’s pressure alarms. during suctioning.
8. Perform oral care q 4 hours. 7. Allows for intervention and recognition of
desaturations.
8. Pt tolerated oral care, decreases secretions
and infection risk.
Evaluation of outcome objectives: Pt met outcome objectives. Oxygen saturation remained above
92% and the airway patent. Patient tolerated all interventions.
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Problem #3: Impaired body defense mechanisms

General Goal: Patient will remain free of signs and symptoms of worsening infection.
Predicted Behavioral Outcome Objective (s): The patient will remain afebrile, show no signs of
worsening wounds, and have improved labs on day of care.

Nursing Interventions Patient Responses

1. Monitor vital signs q 1hr.
2. Assess wound and incision during shift.
3. Monitor laboratory values.
4. Administer Zosyn and vancomycin per
orders.
5. Use proper aseptic technique.
6. Provide daily hygiene and catheter care.
7. Assess urine color, clarity, and odor.
8. Use proper hand hygiene before entering
and leaving room.
1. Pt’s vitals remained within their
parameters and was afebrile.
2. Wound and incision remained free of signs
of worsening.
3. WBC count increased from 15.1 to 18.3.
4. Decreases risk of worsening infection.
5. Decreases risk of infection.
6. Pt tolerated, decreases infection risk.
7. Urine yellow in color and clear. Able to
monitor for signs of UTI.
8. Decreases risk of infection.

Evaluation of outcome objectives: Patient met most of the outcome objectives. The patient remained
afebrile and did not show any signs of worsening wounds. The patient’s laboratory values has not
improved from the day prior.

Problem #4: Impaired Skin Integrity

General Goal: Remain free of worsening wounds and S&S of further injury.
Predicted Behavioral Outcome Objective (s): The patient will have no signs of new skin breakdown
or worsening wounds on day of care.

Nursing Interventions Patient Responses

1. Turn patient q 2 hours. 1. Pt tolerated. Reduced risk of skin
2. Put patients’ feet in heel protector boots. breakdown.
3. Assess patients’ skin for signs of 2. Pt’s heels boggy, takes pressure off heels.
breakdown during shift and when cleaning 3. No new signs of skin breakdown.
up. 4. No signs of worsening wounds.
4. Daily wound dressing changes 5. Skin color appropriate for ethnicity,
5. Assess skin temperature and color. temperature warm.
6. Maintain daily skin hygiene and dry skin 6. Decreases risk of infection/breakdown.
thoroughly. 7. Relieves pressure off bony prominences of
7. Place pillows under patient’s arms. arms.
8. Frequently assess and for and change 8. Patient tolerated linen change, decreases
soiled pads/linen. risk of skin breakdown.
Evaluation of outcome objectives: Patient met the outcome objectives. There were new signs of
breakdown or any worsening of current sites of impaired skin integrity. Patient tolerated
interventions.
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Problem #5: Altered consciousness

General Goal: Maintain or improve level of consciousness.
Predicted Behavioral Outcome Objective (s): The patient will not show any signs of decreasing
level of consciousness on day of care.

Nursing Interventions Patient Responses

1. Assess neurological states q 4hr or as
needed.
2. Provide sedation vacations to assess
LOC.
3. Monitor laboratory values.
4. Assess CPOT and RASS scores.
5. Monitor oxygenation status and O2
saturation.
6. Monitor vital signs q 1hr.
7. Assess neurological status using simple
directions.
8. Provide a low stimulus environment.
Evaluation of outcome objectives: Patient’s LOC did not worsen during the day of care, nor did it
improve.
1. Patient remained only responsive to pain
2. Allows for more thorough neuro
assessment.
3. Calcium 8.2, Chloride 109. Able to
monitor for imbalances that effect LOC.
4. CPOT 0 and RASS -4.
5. O2 saturation remained above 93%.
6. Vital signs WDL for patient parameters.
7. Patient unable to follow commands.
8. Patient’s LOC unchanged. Provides better
environment for patient.

Problem #6: Risk for imbalanced fluid volume

General Goal: Maintain balanced fluid volume.
Predicted Behavioral Outcome Objective (s): The patient will have adequate urine output, clear lung
sounds, and remain free of edema on day of care.

Nursing Interventions Patient Responses

1. Monitor patient’s strict intake and
output.
2. Monitor laboratory values.
3. Monitor vital signs q 1hr.
4. Assess for the presence of edema.
5. Assess respiratory status q 4 hr.
6. Weigh patient daily.
7. Assess mucous membranes
8. Assess patient’s skin turgor.
1. Patient’s urine output 675mL. No BM.
2. Na 142, K 4.4, Cl 109, BUN 21, creatinine
0.9, Ca 8.2
3. BP, HR, and O2 remained WDL for patient.
4. Non-pitting edema present in the BUE.
5. Lung sounds diminished bilaterally no lung
sounds associated with fluid heard.
6. Patients weight was 216lbs. Able to monitor
for weight gain/loss.
7. Pt mucous membranes pink and dry.
8. Pt’s skin turgor WDL.

Evaluation of outcome objectives: Patient met the outcome objectives of having adequate urine
output and clear lung sounds. Lung sounds were diminished but did not show signs of fluid like
crackles for example. Patient did have non-pitting edema present in the BUE.
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Problem #7: Risk for imbalanced nutrition

General Goal: Maintain adequate nutritional intake.
Predicted Behavioral Outcome Objective (s): The patient will tolerate tube feeding and remain free
of signs of malnutrition on day of care.

Nursing Interventions Patient Responses

1. Assess bowel sounds q 4hrs. 1. Bowel sounds active in all four quadrants.
2. Administer tube feeding per orders. 2. Patient tolerating tube feeding at 40mL/hr.
3. Assess residual volume from PEG tube. 3. Residual volume 10mL. Shows GI
4. Assess laboratory values. tolerance of TF.
5. Monitor daily weights. 4. Albumin 2.7, total protein 5.0, RBC 2.91,
6. Monitor strict intake and output. WBC 18.3
7. Assess PEG tube site and dressing. 5. Pt weight was 216lbs.
8. Inspect and palpate patient’s abdomen. 6. Patient’s urine output 675mL. No BM.
120mL of TF.
7. Dressing clean, dry, and intact. No signs of
infection.
8. Abdomen soft, round, and nontender.
Evaluation of outcome objectives: Patient met outcome objects. Patient tolerated tube feeding with
appropriate residual volume assessed. Bowel sounds active all 4 quadrants. Did not show any signs
of malnutrition.

Problem #8: Powerlessness

General Goal: Increase patients’ sense of control in their situation.
Predicted Behavioral Outcome Objective (s): The patient will be informed of their care, condition,
and treatments on day of care.

Nursing Interventions Patient Responses

1. Explain to patient what you are doing 1. Can make pt. feel like they are involved.
before you do it. 2. Makes patient feel cared about.
2. Talk to patient and provide emotional 3. Encourages family’s participation in
support when in the room. patient’s situation.
3. Provide support to patient’s family. 4. Makes patient feel more human.
4. Educate patient on medications 5. Makes patient feel heard and cared for.
administered. 6. Shows patient they are making progress,
5. Advocate for patient when appropriate. little or small.
6. Provide positive feedback to patient for 7. Makes patient more comfortable in
positive outcomes during care. environment
7. Place items in room that patient enjoys. 8. Makes patient feel more comfortable in
8. Provide comforting environment. environment
Evaluation of outcome objectives: Outcome objectives met. Unable to thoroughly assess patient’s
feelings due to patient’s condition but these interventions are useful and beneficial to patients
psychosocial care.