Olivia Engle
Complex Care Clinical
Youngstown State University
Fall 2017
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
#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.
Predicted Behavioral Outcome Objective (s): The patient will remain 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.
Predicted Behavioral Outcome Objective (s): The patient will remain free from signs of skin breakdown during
shift (unblanchable redness, warmth)
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.
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
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.
Predicted Behavioral Outcome Objective (s): Patient will remain free from signs of infection during shift such as
redness, warmth, or any abnormal discharge.
Evaluation of outcome objectives: Patient remained free from signs of infection during shift. No redness, warmth
or discharge was present. Goal met.
Predicted Behavioral Outcome Objective (s): By end of shift, patient will show understanding of verbal
communication by following verbal commands.
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.
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.
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.
Evaluation of outcome objectives: Patient was tolerating tube feeding well. Residual was only 30 mL. Goal met.