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Critical Care Concept Map for Trauma

1. The patient has multiple critical care problems including impaired gas exchange, ineffective airway clearance, acute blood loss, infection, and acute kidney injury from an abdominal gunshot wound. 2. Nursing interventions include monitoring vital signs and lab values, administering medications and blood products, providing respiratory treatments and wound care. 3. Many of the patient's problems are not yet resolved as several key indicators like temperature, lab results, and output remain abnormal, requiring continued nursing care and medical treatment.

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289 views5 pages

Critical Care Concept Map for Trauma

1. The patient has multiple critical care problems including impaired gas exchange, ineffective airway clearance, acute blood loss, infection, and acute kidney injury from an abdominal gunshot wound. 2. Nursing interventions include monitoring vital signs and lab values, administering medications and blood products, providing respiratory treatments and wound care. 3. Many of the patient's problems are not yet resolved as several key indicators like temperature, lab results, and output remain abnormal, requiring continued nursing care and medical treatment.

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api-545001894
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • Critical Care Concept Map: Provides an overview of different critical care concepts including impaired gas exchange, effective airway clearance, altered tissue perfusion, and skin integrity.
  • Problem #2 – Acute Blood Loss: Outlines patient response and interventions related to acute blood loss, focusing on blood volume monitoring and trauma care.
  • Problem #1 – Impaired Gas Exchange: Details nursing interventions and patient responses for managing impaired gas exchange, with specific behavioral objectives and evaluation methods.
  • Problem #3 – Infection: Discusses nursing care aimed at infection prevention and treatment, with resultant patient outcomes and evaluation.
  • Problem #7 – Impaired Skin Integrity: Focuses on maintaining skin integrity through various nursing interventions and addresses the patient responses depending on skin conditions.
  • Problem #4 – Acute Kidney Injury: Elaborates on interventions for acute kidney injury with emphasis on renal function preservation and monitoring.
  • Problem #8 – Impaired Verbal Communication: Explores effective communication strategies for patients with impaired verbal abilities, detailing expected outcomes and nursing approaches.

1

Critical Care Concept Map

#1 Key Problem/ND #8 Key Problems/ND #7 Key Problem/ND


Impaired gas exchange Impaired verbal Impaired skin integrity
communication
Supporting data: Supporting data:
Lactic acidosis Supporting data: Abdominal midline incision
Left pleural effusion Intubated w/staples
Atelectasis Tracheostomy tube (8mm) 2nd abdominal open wound w/
ABG’s: pH 7.217, PCO2 34.1, Follows commands and opens wound vac d/t evisceration
PO2 229.5, HCO3 13.5 eyes but cannot speak Colostomy in RUQ
-uncompensated metabolic Fentanyl IV Q2 hour turn
acidosis Tubes in place (foley, NG,
trach)

#2 Key Problem/ND:
#6 Key Problem/ND
Ineffective airway clearance
Abdominal
trauma/evisceration
Supporting data:
White, thick sputum Reason For Needing Health Care
(Medical Dx/ Surgery) Supporting Data
Diminished breath sounds in
Absent bowel sounds
lower lobes
Gunshot wound to the upper abdomen Tube feed 10ml/hr
Course ronchi
-lactic acidosis d/t acute respiratory failure Distended abdomen
Trach (8mm/cuffed)
Open abdominal wound
Pressure support mode
42 yo male. Full code w/wound vac
PEEP 10
Transverse colon injury
PSV 10
Allergies: none Colostomy in RUQ
FiO2 40%

Key assessments: Respiratory, VS, and lab


values

#3 Key Problem/ND #4 #5 Key Problem/ND


Acute blood loss Key Problem/ND Acute kidney injury
Infection
Supporting data: Supporting Data:
GSW to upper abdomen Supporting Data: Direct Injury to left kidney from
Administering blood WBC: 13.0 gun shot
RBC: 2.27 Lymphocytes 10.4 Foley catheter
Hgb: 6.7 Temperature: 100.8 On dialysis
Hct: 21.9 Administering antibiotics Creatinine 1.8
Platelets: 572 (Zosyn) and antipyretics BUN 44
Open abdominal wound w/wound (Tylenol) Cl 116
vac

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


2

Problem # ___1____: Impaired gas exchange


General Goal: Increase gas exchange

Predicted Behavioral Outcome Objective (s): The patient will…… have normal ABG’s and tolerate lower
FiO2 of 40% and maintain oxygen saturation >93%

Nursing Interventions Patient Responses

1. Position HOB at 45 degrees 1. Maintained elevated HOB


2. Monitor oxygen saturation >93% 2. Oxygen saturation 100%
3. Monitor ABG’s 3. ABGs normal
4. Assess breath sounds Q2h 4. Diminished in lower lobes
5. Pressure support ventilation 5. Tolerated
6. FiO2 40% 6. Tolerated, SPO2 100%

Evaluation of outcome objectives: Patient is tolerating lower ventilator settings and gas exchange is improving.

Problem # _2______: Ineffective airway clearance


General Goal: Increase airway clearance

Predicted Behavioral Outcome Objective (s): The patient will……have increased breath sounds and thinner
secretions

Nursing Interventions Patient Responses

1. Assess breath sounds 1. Diminished in lower lobes


2. Assess secretions 2. Thick, white secretions
3. Suction tracheostomy tube when needed 3. Suctioned several times during care
4. Elevate HOB 4. HOB remained >30
5. Assess cuff pressure 5. Cuff pressure stayed at 25
6. Monitor SPO2 6. SPO2 100%
7. Provide oral care Q1h 7. Swabbed and suctioned mouth
8. Provide humidification PRN 8. Patient did not need
Evaluation of outcome objectives: Patients airway needs further clearance. Secretions are still thick and
required suctioning.

Problem # __3_____: Acute blood loss


General Goal: Patient will not lose more blood

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


3

Predicted Behavioral Outcome Objective (s): The patient will…… have normal RBC, Hgb, and Hct on the
day of care.

Nursing Interventions Patient Responses

1. Monitor RBC, Hbg, Hct 1. All were low


2. Administer blood products 2. 2 units administered
3. Monitor wound vac for drainage 3. A lot of drainage present
4. Assess mucous membranes 4. No petechia, bruising
5. Monitor heart rate 5. Patient tachycardic (130)
6. Monitor blood pressure 6. Blood pressure elevated (150/79)
Evaluation of outcome objectives: Patient needs further monitoring for blood loss d/t trauma

Problem # ___4____: Infection


General Goal: Infection will clear
Predicted Behavioral Outcome Objective (s): The patient will…… not show signs of infection and have
decreased temperature on day of care

Nursing Interventions Patient Responses

1. Monitor temperature 1. Temperature elevated 100.8


2. Assess wounds for drainage/odor 2. No drainage/odor
3. Monitor WBC count 3. WBC count elevated 13
4. Administer antibiotics (Zosyn) 4. 1 dose administered
5. Use cooling blanket for temp 5. Cooling blanket on
6. Use aseptic technique for dressings 6. Dressing change done prior
7. Perform hand hygiene before interaction 7. Washed hands w/each interaction
8. Monitor urine output/color 8. Normal output, yellow, clear
Evaluation of outcome objectives: Patient needs more rounds of antibiotics, infection still present

Problem # ___5____: Acute kidney injury


General Goal: Kidneys will regain normal function

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


4

Predicted Behavioral Outcome Objective (s): The patient will…… have normal BUN/creatinine levels and
normal urine output on day of care

.
Nursing Interventions Patient Responses

1. Assess urine output hourly 1. Urine output 75ml/hr


2. Assess color/character of urine 2. Urine yellow and clear, no sediment
3. Monitor BUN/creatinine 3. BUN/Creatinine elevated
4. Weigh daily 4. Weighed 219 ( inc 2lb from prior day)
5. Administer antihypertensives 5. Administered metoprolol
6. Dialysis every other day 6. Not on day of care
7. Monitor HR/BP 7. Heart rate and BP elevated
8. Monitor edema in extremities 8. Generalized upper/lower, non-pitting
Evaluation of outcome objectives: Kidneys are showing progress of recovery, BUN/creatinine will continue
to monitor

Problem # ___6____: Abdominal trauma/evisceration


General Goal: Patient’s wound will remain intact
Predicted Behavioral Outcome Objective (s): The patient will…… have bowel sounds and signs of healing
from evisceration

.
Nursing Interventions Patient Responses

1. Assess bowel sounds 1. Absent bowel sounds


2. Assess for distention 2. Abdomen distended and hard
3. Administer tube feed 3. Tube feed ran at 10ml/hr
4. Monitor wound vac drainage 4. Wound vac drained large amt of blood
5. Assess output of stool 5. No stool output on day of care
6. Assess colostomy site 6. No swelling or skin breakdown
7. Monitor signs of infection 7. No signs, no redness, foul odor

Evaluation of outcome objectives: Patients bowels need further time for recovery and continued monitoring

Problem # __7_____: Impaired skin integrity


General Goal: Skin will heal and not show signs of breakdown
Predicted Behavioral Outcome Objective (s): The patient will……show no signs of further skin breakdown on
other sites of body on day of care

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


5

Nursing Interventions Patient Responses

1. Turn Q2h 1. Turned every 2h, tolerated


2. Evaluate 1st abdominal incision 2. Stapled, clean, and dry
3. Evaluate skin around wound vac 3. Skin is clean and dry, no redness
4. Monitor for drainage and odor 4. No drainage or odor
5. Assess stoma 5. Stoma is beefy red, no swelling
6. Assess restraints Q2h 6. Skin is not showing breakdown
7. Assess characteristics of wound 7. Large covered by wound vac
8. Proper placement of tubes 8. Foley placed off of skin
Evaluation of outcome objectives: Patients skin is not showing signs of further breakdown in other areas.

Problem # __8_____: impaired verbal communication


General Goal: patient will learn new way to communicate
Predicted Behavioral Outcome Objective (s): The patient will…… learn to nod to yes or no questions and
follow commands on day of care

Nursing Interventions Patient Responses

1. Assess orientation and alertness 1. Patient alert and oriented to situation


2. Teach new way to communicate 2. Patient will nod yes or no to questions
3. Speak in normal tone, not loud 3. Spoke softly and clearly
4. Ask yes or no questions 4. Patient responded by nodding
5. Speak slowly and short sentences 5. Patient understood easily
6. Provide stimuli to patient 6. Provided TV for distraction
7. Place important objects w/in reach 7. Call light placed in hand
8. Maintain eye contact when speaking 8. Patient maintained eye contact as well
Evaluation of outcome objectives: Patient is responding well with new communication while he has the
tracheostomy in place.

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

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