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Assessment and Concept Map Care Plan

For

Critical Care Patient

Created by

Abigail Collins

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

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Step 2. Support problems with clinical patient data, including abnormal physical
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab
tests, medical history, emotional state and pain. Also, identify key assessments that are
related to the reason for health care (chief medical diagnosis/surgical procedure) and put
these in the central box. If you do not know what box to put data in, then put it off to the
side of the map.

#5 Key Problem/ND: Impaired #6 Key Problems/ND: Imbalanced #7 Key Problem/ND: Risk for
Spontaneous Ventilation Nutrition: less than body Unstable Glucose
requirements
Supporting Data Supporting data:
Pt. RRT w/ severe levels of Supporting data: Hx insulin dependent T2DM
hypoxia that required ventilation NPO d/t vent Lispro sliding scale
A/C mode Dextrose drip 100 mL/hr. Dextrose drip (100 mL/hr.)
Rate 20 Albumin 3.0 BS check q. 4 hrs.
FiO2 65 Hx of diabetes (glucose check Q Last glucose level was 244
TV 470 4 hrs.) - lispro
PEEP 15 No bowel movements w/
SpO2 96 hypoactive bowel sounds
Nimbex and Fentanyl On multivitamin and vit. D

#4 Key Problem/ND: Fluid Volume

#8 Key Problem/ND: Impaired
deficit
verbal Communication
Supporting data: Reason For Needing Health Care
Supporting data:
Dark urine (Medical Dx/ Surgery)
Intubated
Oliguria Acute on chronic resp failure with hypoxia
Assess cuff pressure
Dry mucous membranes Interstitial lung disease
Nimbex
Some tenting, but not severe Hx of HFpEF, T2DM
Fentanyl
Weak pulse 56 yo male, full code
No eye opening, or response
to verbal command
Key assessment
Neuro, with assessment of therapeutic
effectiveness of paralytics

Allergies: NKA

#3 Key Problem/ND: Diminished #2 Key Problem/ND: Impaired Gas #1 Key Problem/ND: Risk for
Urine output (with a rule out for exchange drug imbalance (paralytics)
AKI)
Supporting data: Supporting data:
Supporting data: Rt. Interstitial Lung disease; Nimbex
Pt was having UO of 10 mL in 1 acute on chronic respitory failure Fentanyl
hr ABG: pH 7.4, CO2 46.2, O2 On ventilator
Fluid Challenge, failed 118, HCO3 28 Reason: fighting vent and hx of
Foley Catheter not draining urine FiO2 65 pulling out vent, Fentanyl was
BUN 71 PEEP 15 not enough to relax
Creatine 1.4 RR 20
SPO2 96 w/ FiO2 of 65

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: risk for drug imbalance r/t paralytics
General Goal: pt. will remain paralyzed and sedated safely

Predicted Behavioral Outcome Objective (s): The patient will…… not have an overresponse or underresponse
to the train-of-four test (or not breathe over vent)

on the day of care.

Nursing Interventions Patient Responses

1. Train-of-four 1. Equipment not working

2. RR 2. 20, not breathing over vent
3. Line patency 3. Line is patent (saline flush)
4. Dosage check 4. Dosage is correct with orders
5. Pain responses 5. Pt. has no response to pain
6. HR 6. HR remains at baseline of 54
7. Eye response to commands 7. Eyes do not spontaneously open
8. 8.

Evaluation of outcome objectives: pt. remains paralyzed and sedated within therapeutic range

Problem # 2: impaired gas exchange

General Goal: increased gas exchange

Predicted Behavioral Outcome Objective (s): The patient will………have ABG’s WNL and have SpO2
remain above 95
on the day of care.

Nursing Interventions Patient Responses

9. Assess breath sounds

10. Assess ABG 9. Breath sounds are becoming clear
11. Check SpO2 Q2 hrs. 10. pH 7.4 CO2 46.2 O2 118.4 HCO3 28
12. Assess chest X-ray 11. 96
12. ETT placement WDL, R>L perfusion
13. Keep HOB elevated 30 degrees
13. HOB elevated 30
14. Suction Q2 hrs.
14. No secretions
15.
15.
Evaluation of outcome objectives: Pt. ABG are in compensated resp. acidosis, SpO2 remained above 95 (at
96-98)
Problem # 3: diminished urine output
General Goal: pt will have increased urine output

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

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Predicted Behavioral Outcome Objective (s): The patient will…… have urine output of more than 120 mL in
1 hr
on the day of care.

Nursing Interventions Patient Responses

16. Assess mucus membranes 16. dry

17. Assess skin turgor 17. some tenting
18. Fluid challenge 18. failed, no response from kidneys
19. Assess foley line 19. no sediment, not laying on line
20. Flush foley 20. received more output (50)
21. 21.
22. 22.
23. 23.

Evaluation of outcome objectives: pt. catheter line seemed to be blocked, after flushing line bag received 400
mL of urine, not AKI

Problem # 4: fluid volume deficit

General Goal: pt. will not be dehydrated

Predicted Behavioral Outcome Objective (s): The patient will…… no longer show signs of dehydration and
urine output will increase to 120 mL/hr

on the day of care.

Nursing Interventions Patient Responses

24. Assess mucus membranes 24. dry

25. Assess skin turgor 25. some tenting
26. Assess line patency 26. lines are patent
27. Check urine output 27. UO 10 ml -> 400 after flush
28. Mouth care 28. Brushed and suctioned
29. Assess pulses 29. Weak
30. 30.
31. 31.

Evaluation of outcome objectives: pt still remains dehydrated, will talk with nurse about maybe getting orders
for NS on top of dextrose, meds seem to be drying him out

Problem # 5: impaired spontaneous ventilation

General Goal: maintain ventilation

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

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Predicted Behavioral Outcome Objective (s): The patient will…… tolerate ventilator on ordered settings and
have ease of respirations
on the day of care.

Nursing Interventions Patient Responses

32. Assess vent settings 32. AC/VC: rate 20 FiO2 65 TV 470

33. Monitor SpO2 PEEP 15
34. Mouth care q2 hrs 33. 96-98
35. RR 34. 20
36. Assess breath sounds 35. clear
37. HOB 30 degrees 36. elevated 30 degrees
38. Assess for drug therapy of 37. seems to be WDL
Fentanyl/Nimbex 38.
39. 39.

Evaluation of outcome objectives: pt. does not breathe over vent, the settings he is on seems to be allowing
ease of respirations and maintenance of ventilation

Problem # 6: imbalanced nutrition: less than body requirements

General Goal: improved nutritional status

Predicted Behavioral Outcome Objective (s): The patient will…… pt. weight will remain at 266

on the day of care.

Nursing Interventions Patient Responses

40. Assess bowel sounds 40. hypoactive

41. Assess NG placement w/ CXR 41. NG is correctly placed
and air bolus 42. Albumin 30 electrolytes WDL
42. Monitor labs 43. Bed 30 degrees
43. Elevate HOB 30 degrees 44. No stool this shift
44. Assessment of stool 45. 266
45. Weigh 46. Line is patent
46. Assess line patency 47.
47. Check dosage of dextrose Dextrose runs at 100mL/hr per orders

Evaluation of outcome objectives: pt. weight remains stable

Problem # 7: risk for unstable glucose

General Goal: pt BS will be WDL

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

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Predicted Behavioral Outcome Objective (s): The patient will……pt. Blood glucose will be within 74-99

on the day of care.

Nursing Interventions Patient Responses

48. BS checks q 4 hrs. 48. 244

49. Insulin if needed 49. Lispro administered
50. Line patency 50. Line patent
51. Dextrose dosage check 51. Running at 100 ml/hr per orders
52. 52.
53. 53.
54. 54.
55. 55.

Evaluation of outcome objectives: pt BS still fluctuates with the need for insulin administration

Problem # 8: impaired communication

General Goal: pt. will remain sedated

Predicted Behavioral Outcome Objective (s): The patient will…… remain sedated and free of anxiety related
to the ventilator and NG tube
on the day of care.

Nursing Interventions Patient Responses

56. Neuro assessment 56. Pupils round and reactive, no

57. ETT tube placement spontaneous eye movement
58. Cuff pressure 57. ETT correctly placed, lip line same
59. NG tube placement 58. Cuff pressure normal
60. Free from pain 59. NG tube correctly placed
61. Therapeutic levels of 60. CPOT assessment 0
Nimbex/Fentanyl 61. Pt. remains safely sedated and
62. paralyzed
62.

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

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

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

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

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

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Evaluation of outcome objectives: pt. remains sedated and unable to communicate needs. This is for his own
safety in order to maintain ETT/NG/IV-line placement (he pulls them)

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