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Assessment and Concept Map Care Plan

For
A Critical Care Patient

Olivia Engle
Complex Care Clinical
Youngstown State University
Fall 2017

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.

#1 Key Problem/ND: Ineffective Airway #2 Key Problems/ND: Acute Pain #3 Key Problem/ND: Risk for
Clearance Related to Trauma Impaired Skin Integrity
Evidenced By: Roxicodone via NG Evidenced By:
Ronchi in all lobes (except left lower Fentanyl Continuous IV Surgical incisions on left flank
lobe) Robaxin via NG Stitches on left leg
Tracheostomy FLACC score of 3 Several abrasions all over body
Thick, tan sputum Stitches present on left flank, and Immobility
Pneumothorax left leg Patient in 4-point restraints
Patient needs suctioned often Close fracture of multiple ribs on Temperature 100.1-102.6 degrees
left side F
Closed nondisplaced fracture of left Central Line
scapula Turn Q2
Closed fracture of body of sternum

#6 Key Problem/ND: Anxiety

#4 Key Problem/ND: Impaired Gas
Evidenced By:
Exchange
Restlessness
Evidenced By:
Irritability
Reason For Needing Health Care Left pneumothorax
HR: 112-127
(Medical Dx/ Surgery) Tracheostomy
BP: 153/81-128/81
Trauma (motor cycle accident) Left lower lobectomy
Respiratory Difficulty
Surgical Procedure: Thoracotomy with left lower Atelectasis present on CXR
Continuous fentanyl IV
lobectomy Ronchi present in all lobes
Ativan via NG
28-Year-old male (except left lower)
Full Code 10/3 ABG’s indicated
No known allergies uncompensated respiratory
Key assessments: VS with focus on respiratory alkalosis (pH: 7.488, CO2: 34.5,
PO2: 104.9, HCO3: 24.0)

#5 Key Problem/ND: Risk for Infection #8 Key Problem/ND: Imbalanced #7 Key Problem/ND: Impaired Verbal
Evidenced By: Nutrition Less than Body’s Communication
Surgical Procedures: Requirements Evidenced By:
Thoracotomy, left lower lobectomy, Evidenced By: Tracheostomy
tracheostomy Tube feed 45 mL/hr protein modular Continuous fentanyl drip (sedative)
Central line Calcium 8.1 Attempts to write down thoughts
Temperature 100.1-102.6 Total Protein: 5.6 but is unable to do so
(hyperthermia) Generalized weakness
Ronchi present in all lobes (except
left lower lobe)
Increased HR (112-127)
Malnutrition (tube feeding)

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____: Ineffective airway clearance
General Goal:

Predicted Behavioral Outcome Objective (s): The patient will remain free from signs of hypoxia.

The patient will maintain respirations between 12 and 24 during shift.

Nursing Interventions Patient Responses

1. Nurse will suction patient 1. Tracheostomy was suctioned

2. Nurse will assess lung sounds
3. Nurse will monitor oxygen
patient’s saturation
4. Nurse will monitor patient’s
respirations
5. Nurse will instruct patient to
cough and deep breath
6. Assess for signs of hypoxia
twice during shift
2. Ronchi present in all lobes
(except left lower lobe)
3. Saturation remained above 98%
4. Respirations remained between
14-23
5. Patient was coughing effectively.
6. Patient remained free from signs
of hypoxia

Evaluation of outcome objectives: Patients respirations remained between 12 and 24 during shift. Patient was also
able to cough effectively. Goal met.

Problem # ___2____: Acute Pain Related to Trauma

General Goal: The patient will remain free from pain
Predicted Behavioral Outcome Objective (s): The patient will have a pain rating of 0 on the FLACC scale during
shift

Nursing Interventions Patient Responses

1. Nurse will assess patient’s pain Q 1. Patient’s pain was a 3 on FLACC

hour scale
2. Nurse will use appropriate pain 2. FLACC scale used for this patient
rating scale
3. Nurse will use non- 3. Patient’s family provided excellent
pharmacological pain relief methods distraction; TV was also used as
when possible distraction
4. Nurse will administer prescribed 4. Patient was given Roxicodone and
medications when patient is in pain Robaxin for pain

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

 Evaluation of outcome objectives: Patient had a pain rating of 3 on the FLACC scale during shift. Goal not met.
Pain was reevaluated every hour and pain did improve after medications were administered. 4

Problem # ____3___: Impaired Skin Integrity

General Goal: The patient’s skin integrity will remain intact.

Predicted Behavioral Outcome Objective (s): The patient will remain free from signs of skin breakdown during
shift (unblanchable redness, warmth)

Nursing Interventions Patient Responses

1.

1. Nurse will assess patient’s skin for 1. Patient’s skin was free from
any signs of breakdown breakdown
2. Nurse will turn patient every 2 hours 2. Patient was turned every two hours
to prevent breakdown during shift
3. Nurse will assess patient’s need for 3. Patient’s restraints were taken off
restraints during shift during shift

Evaluation of outcome objectives: Patients skin remained free from signs of breakdown during shift. Skin was
assessed every two hours and remained free from unblanchable redness and warmth. Goal met.

Problem # ___4____: Impaired Gas Exchange

General Goal: Increased Gas Exchange

Predicted Behavioral Outcome Objective (s): Patient will maintain ABG’s within normal limits, and will maintain
oxygen
1. saturation above 95% during shift. 4.
2. 5.
3.
Nursing Interventions Patient Responses

1. Nurse will assess patient’s lung 1. Ronchi present in all lobes

sounds 2. Oxygen saturation remained above
2. Nurse will assess patient’s oxygen 98%
saturation 3. ABG’s for 10/4 indicated
3. Assess ABG’s uncompensated metabolic alkalosis
4. Keep HOB elevated to improve gas 4. Patient’s HOB elevated during shift
exchange

Evaluation of outcome objectives: Patient’s ABG’s were not within normal limits, but patient did maintain oxygen
saturation above 98%. Patient’s gas exchange is improving. Goal not met.

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

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Problem # ____5___: Risk for Infection
General Goal: Patient will remain free from infection

Predicted Behavioral Outcome Objective (s): Patient will remain free from signs of infection during shift such as
redness, warmth, or any abnormal discharge.

Nursing Interventions Patient Responses

1. Take vital signs 1. Patients temperature was elevated

2. Assess for redness, warmth and any (100.1-102.6)
discharge. 2. No redness, warmth, or discharge.
3. Perform hand hygiene with all patient 3. Hand hygiene performed
care. 4. Ronchi present in all lobes (except left
4. Assess lung sounds lower lobe)
5. Assess for abnormal lab values 5. WBC’s within normal limits
6. Assess surgical sites for proper
healing 6. All surgical sites healing appropriately

Evaluation of outcome objectives: Patient remained free from signs of infection during shift. No redness, warmth
or discharge was present. Goal met.

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

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Problem # ____6___: Impaired verbal communication
General Goal: Effective Communication

Predicted Behavioral Outcome Objective (s): By end of shift, patient will show understanding of verbal
communication by following verbal commands.

Nursing Interventions Patient Responses

1. Nurse will use a familiar person when 1. Patient’s mother and girlfriend were
attempting to communicate with the at bedside assisting in communication
patient 2. Patient alert, and oriented to person
2. Neurological Assessment 3. Soft voice was used when
3. Use a soft, clear voice when communicating with patient
communicating with patient 4. Patient was capable of following
4. Assess ability of patient to follow verbal commands
verbal commands 5. Fentanyl continued to be used as
5. Assess patient’s need for sedation sedative during shift.
during shift

Evaluation of outcome objectives: Patient was excellent at following verbal commands. Patient also attempted to
write down thoughts, but was having difficulty doing so and became frustrated. Patient continues to improve
towards effective communication.

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

Problem # ____7___: Anxiety related to trauma
General Goal: Patient will remain free from anxiety
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Predicted Behavioral Outcome Objective (s): During shift patient will not exhibit any signs of anxiety (i.e.
restlessness, increased heart rate).

Nursing Interventions Patient Responses

1. Observe patient for what causes 1. Patient becomes anxious when having
anxiety difficulty breathing due to secretions in
2. Observe for signs and symptoms of airway.
anxiety 2. Patients heart rate would increase
3. Remove sources of anxiety when becoming anxious and patient
4. Provide comfort measures and a calm would also appear restless.
environ 3. Patient was suctioned often during
5. Allow family presence to provide shift in order to improve breathing
comfort 4. Patient’s room was kept as quiet as
6. Speak in a soft tone of voice and possible, and blankets were provided for
provide comforting touch when comfort.t
indicated 5. Family was present at bedside for
7. Administer medications prescribed to most of shift.
relieve anxiety. 6. Patient was spoken to in a soft tone of
voice.
7. Lorazepam was administered via NG
tube

Evaluation of outcome objectives: Patient did not remain free from symptoms related to anxiety during shift.
Patient became very anxious when having difficulty breathing and being suctioned. Goal not met.

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

 Problem # ____8___: Imbalanced Nutrition: Less than body’s requirements
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General Goal: Adequate Nutrition

Predicted Behavioral Outcome Objective (s): Patient will tolerate protein modular tube feeding at 45 mL/hour
during shift, as evidenced by a residual less than 100 mL.

Nursing Interventions Patient Responses

1.Patient’s bowel sounds were active in

1.Nurse will assess GI status
2. Nurse will assess residual
3. Monitor labs
4. Nurse will assess whether patient is
passing flatus or having bowel
movements.
all 4 quadrants; abdomen was soft and
nontender.
2. Residual of 30 mL was present
3. Labs on day of care indicated low
calcium and low total protein
4. Patient was passing flatus, but did not
have a bowel movement during shift.

Evaluation of outcome objectives: Patient was tolerating tube feeding well. Residual was only 30 mL. Goal met.

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