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Critical Care Concept Map

Karlye Burns

Professor Heidi Alflen

Nurs 4840L

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

Key Problem # 1 Key Problem # 2
Ineffective Airway Clearance Decreased Cardiac Output Key Problem2 #6
Ventilator on spontaneous VC mode (ETT 7.5 & 23 at the H/O Atrial fibrillation, DVT, massive Impaired Verbal
lip line, FiO2 = 30%, TV = 400, PEEP = 5%) Communication
stroke, CAD, HTN,
CPAP (30% FiO2) Presented to ED (2/7/20)
SPO2 = 97% on vent
Hypercholesteremia
Pacemaker unresponsive
Sedated with Fentanyl
Diminished breath sounds Presence of IVC filter Intubated
Creamy, yellow sputum Irregular Rhythm and pulse Baseline is confusion
Non-productive cough S1 & S2 heard according to nursing home
Needs suctioned often (at least twice an hour) Capillary refill <3 seconds where she arrived from
ABG results on admission (2/7/20) Compensated All pulses weak (+1) with doppler Speaking to patient and using
Respiratory Alkalosis (pH = 7.41, PCO2= 24.8, PO2= 155, Generalized +1 edema light touch to prevent SPA’s
HCO3= 16) and to decrease anxiety
EKG results (2/7/20) Afib with rapid
Chest x-ray results: (2/10/20) Interval improvement of a
ventricular response, left axis (patient has H/O
small right pleural effusion with mild patchy residual right
basilar airspace disease deviation, inferior infarct, RBBB, depression/anxiety)
During intubation patient had an episode of large volume Ant/septal & lateral ST-T
emesis that resulted in aspiration pneumonia abnormality may be d/t MI
Duo-neb ordered Q8H Troponin level (2/7/20) = 0.085
Platelets (2/11/20) = 108
Cordarone/D5W ordered as IV drip
End of shift BP = 94/50 (70)

Key Problem #5 Key Problem #4

Bowel Incontinence Impaired Skin Integrity
Tube feed: Pivot 1.5 cal @ 30 Reason For Needing Health Care Stage 4 sacral wound
mL/hr via PEG tube Sepsis secondary to UTI, Aspiration Neck wound
Abdomen soft, nontender, round Pneumonia, Acute Respiratory Failure IJ triple lumen
Hypoactive bowel sounds in all four Arterial line
with Hypoxia
quadrants H/O massive stroke in right MCA
Key assessments: territory with residual left sided
Unable to verbalize need to have
bowel movement – sedated Daily ABG’s hemiparesis has led to immobility
Left sided hemiparesis Strict I/O (6 hr intake during shift = 670 resulting in pressure ulcer
Colace ordered PO Q12H to prevent mL, 6 hr output during shift = 350 mL Serum Albumin = 2.1
constipation d/t immobility Vitals Q1H PEG tube
(BP = 138/70, MAP = 70, HR = 115, RR Medihoney ordered – topical daily
= 23, SPO2 = 97%) for sacral wound
Neuro checks Q4H

Key Problem # 7
Risk for infection Key Problem #3
Drainage from foley upon admission Impaired Urinary Elimination
(2/7/20) was purulent, foul smelling, Key Problem # 8 Drainage from foley upon admission (2/7/20) was
tea colored and pus like Risk for impaired oral mucous purulent, foul smelling, tea colored and pus like
Foley in place membrane Catheter removed and replaced with a 14 french
Stage 4 sacral pressure ulcer ETT in place indwelling foley
Neck wound Dry mucous membranes Urine characteristics (2/11/20) light amber, pink
IJ triple lumen in place Coated tongue color with cloudy clarity and sediment
Arterial line in place Halitosis 24 hr intake = 3913 mL & output = 1565 mL
WBC on admission (2/7/20) = 20.5 on Cumulative fluid balance = 2348 mL
date of care (2/11/20) = 13.4 6 hr intake = 670 mL & output = 350 mL
Serum Albumin = 2.1 2/7/20 Renal ultrasound results: Questionable debris
Creamy, yellow sputum vs a mass within the urinary bladder, urinary
Step(2/11/20)
Urine characteristics 3:. light bladder is collapsed around a foley
amber, pink colorLASTLY-
with cloudylabel
clarityt WBC on admission (2/7/20) = 20.5 on date of care
and sediment (2/11/20) = 13.4 d/t UTI
Step 4: Identific. Chloride on admission = 109 on date of care = 117
BUN on admission = 72 on date of care = 21
Step 5: Evaluation of Outcomes Creatinine on admission = 2.25 on date of care =
0.51
Phos-NaK packet ordered PO t.i.d as adjunct
therapy for UTI
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis,
Zosyn 2002.
IV Q8H for UTI
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Problem # 1: Ineffective Airway Clearance

General Goal: Maintain clear, open airway
The patient will handle suctioning well and exhibit
Predicted Behavioral Outcome Objective (s):
readiness for extubation on the day of care.

Nursing Interventions Patient Responses

1. Auscultate lungs 1. Patient sedated, lung sounds diminished

2. Monitor O2 Sat 2. 97-100%
3. Assess ABG’s 3. Patient tolerated well, took from art line
4. Explain suctioning & reassure during it 4. HR increased & patient became anxious,
5. Turn Q2H Ativan was administered
6. Give medications as prescribed 5. Patient was not turned during shift
6.Duo-neb & Neo-synephrine/NS given

Evaluation of outcome objectives: Patient

unable to clear secretions on own and struggled to
tolerate suctioning at times – Goal not met

Problem # 2: Decreased Cardiac Output

General Goal: Maintain patient specific normal parameters for blood pressure
Predicted Behavioral Outcome Objective (s): The patient will have stable blood pressure readings,
show signs of good tissue perfusion and have strong, palpable pulses on the day of care.

Nursing Interventions Patient Responses

1. Record I/O 1. Intake = 670 mL output = 350 mL – patient

2. Auscultate heart sounds
3. Closely monitor for symptoms of heart
failure and decreased cardiac output
4. Place on cardiac monitor
5. Monitor lab results
6. Monitor bowel function to prevent straining
tolerating tube feeding well and output measured
via indwelling foley catheter
2. S1 & S2 heard – patient sedated
3. Skin cool, diminished peripheral pulses,
generalized edema – patient sedated
4. Irregular rate & rhythm – Afib present
5. Date of care: Na= 145, K= 3.7, Creat = 0.51
Drawn from A-line, pt sedated & tolerated well
6. Colace administered as ordered PO Q12H – pt
tolerating well

Evaluation of outcome objectives: Patient has weak pulses and exhibited a drop in blood
pressure (94/50) – Goal not met

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

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Problem #3: Impaired Urinary Elimination

General Goal: Maintain adequate hourly output
Predicted Behavioral Outcome Objective (s): The patient will maintain balanced I/O with clear,
odor free urine on the day of care.

Nursing Interventions Patient Responses

1. Observe urine characteristics 1. light amber, pink with cloudy sediment

2. Cleanse perineal area & keep dry observed in catheter bag - pt tolerated well
3. Monitor lab results 2. No catheter care was provided during shift
3. BUN= 21, Creat= 0.51, WBC= 13.4

Evaluation of outcome objectives: Patient

still exhibits signs and symptoms of UTI such as light
amber, pink urine with cloudy clarity and sediment present and elevated WBC count – Goal
not met

Problem # 4: Impaired Skin Integrity

General Goal: No further skin breakdown
Predicted Behavioral Outcome Objective (s): The patient will tolerate Q2H turns well on the day of
care.

Nursing Interventions Patient Responses

1. Monitor sites for signs of infection
2. Minimize exposure of incontinence to
wound site
3. Administer medications as ordered
4. Monitor skin integrity where tape secures
catheter tube
5. Implement Q2H turns and do not place on
site of sacral wound
1. No changes with sacral wound, neck wound
had purulent drainage – cleansed wound and
bandaged it – pt tolerated well and showed no
signs of pain
2. Indwelling foley in place and no bowel
movements during shift
3. Medihoney applied daily – pt tolerated well
4. No signs of skin breakdown – pt tolerated well
5. Pt was not turned during shift

Evaluation of outcome objectives: The patient was never turned throughout the shift – Goal not
met

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

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Problem # 5: Bowel Incontinence

General Goal: Soft, formed stools
Predicted Behavioral Outcome Objective (s): The patient will have one formed bowel movement
on the day of care.

Nursing Interventions Patient Responses

1. Wash perineal area after elimination 4.

with soap and water and apply moisture 1. Pt did not have bowel movement
barrier ointment 2. Colace administered as ordered Q12H – pt
2. Administer medication as ordered tolerating well
3. Auscultate bowel sounds 3. Hypoactive bowel sounds in all four
quadrants- pt tolerated well
4. Assess abdomen 4. Soft, nontender and round – pt tolerated
well

Evaluation of outcome objectives: The patient did not have a bowel movement during the shift –
Goal not met

Problem # 6: Impaired Verbal Communication

General Goal: Decrease Anxiety & speak to patient while intubated and sedated
Predicted Behavioral Outcome Objective (s): The patient will display a decrease in anxiety r/t inability to
verbalize during suctioning on the day of care

Nursing Interventions Patient Responses

1. Observe for nonverbal cues 1. Pt becomes tense during suctioning

2. Explain everything being done before
doing it or touching the pt
3. Reduce stimuli in the room
2. Pt tolerated well
3. Overhead lights off and monitor parameters
set to be pt specific to reduce beeping – pt
tolerated well

Evaluation of outcome objectives: Patient given Ativan before suctioning and tolerated
suctioning well – Goal met

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

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Problem #7: Risk for Infection

General Goal: No signs of infection
Predicted Behavioral Outcome Objective (s): The patient will remain free from infection on day of
care.

Nursing Interventions Patient Responses

1. Maintain sterile technique when changing
IJ dressing
2. Perform proper hand hygiene when
entering and leaving room and before contact
with the pt
3. Suction secretions PRN
4. Limit visitors
5. Properly clean the catheter
1. Dressing was not due to be changed on date of
care
2. Pt tolerated well
3. HR and anxiety increased during suctioning,
overoxygenated and administered Ativan and pt
was able to handle suctioning well
4. No visitors present on day of care
5. Pt bathing was done the night prior

Evaluation of outcome objectives: Patient

admitted with sepsis d/t UTI and developed aspiration
pneumonia d/t emesis during intubation, symptoms of infection are beginning to lessen and
no new infection is present, but infection is still present – Goal not met

Problem # 8: Risk for Impaired Oral Mucous Membrane

General Goal: Moist oral mucous membranes free of breakdown
Predicted Behavioral Outcome Objective (s): The patient will remain free from ulceration and
tolerate oral care Q4H on day of care.

Nursing Interventions Patient Responses

1. Provide oral care Q4H 1. Oral care provided after suctioning – pt

tolerated well
2. Use foam swabs to moisten the mouth 2. Pt tolerated well
3. Use chapstick 3. Pt tolerated well

Evaluation of outcome objectives: Patient has dry mucous membrane but no signs of ulceration
and tolerated oral care – Goal met

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