#1 Ineffective breathing pattern

#6 #3
• Abnormal respiratory rate: 22rr
Impaired electrolyte imbalance • Breath sounds: diminished and Ineffective airway clearance
1
• Running free water at 250ml/hr to labored • O2 sat maintained
improve Na • O2 sat: 97% above 92%
• Urine output Q1hr: 1100cc in 5 • A/C vent: rate 16, FiO2 35, TV 500, • Pulse ox: 97%
hours PEEP 5 • Suction in use: thick,
• Strict I & O Q1hr • Abnormal ABG (metabolic alkalosis) yellow sputum removed
• Weight: 120kg • Accessory muscle use • Lung sounds:
• Pulse Q1hr: 57bpm, 22rr • Diaphoresis diminished and labored
• Edema: +3 present b/l upper and • HX of OSA • HOB elevated at 45
lower extremity • Assess for oversedation degrees: promote
• Secretions: thick and yellow through secretions
• Neuro status: sedated and lethargic
suction as needed • Vital signs; 22rr, 97%
• Sodium level: 156
• Elevated HOB 45 degrees • Pt intubated and on a
• Potassium: 3.1
• Frequent repositioning ventilator
• Calcium: 8.0
• Ice packs to keep cool
#7
#4 Acute Renal Failure Fluid volume excess
Pulse ox: 97% • 24hr Intake: 3593.4ml
Decreased cardiac output 24hr; Output: 1175ml
Resp. rate and effort: 22rr, labored
• Heart rate: 57bpm (bradycardia) • Foley catheter for output
Skin color: pale and dry membranes
• Low blood pressure: 96/50 Cap refill: <3 seconds • Pitting edema +3 of
• Heart sounds: S1 and S2 present, no O2 saturation: remained >97% hands, feet and legs
S3 or S4 heard Heart rate: 57bpm • Weight 120kg
• EKG monitoring: sinus bradycardia Blood pressure: 96/50 (62) • Blood pressure and heart
• O2 sat: 97% Secretions: thick and yellow rate:96/50 and 57bpm
• MAP: 60 Intake and output: Q 1hr • Lung sounds: diminished
• A/C vent: rate 16, FiO2 35, TV Foley catheter 14g: 1100mL • Level of consciousness:
500, PEEP 5 Weight: 120kg sedated, lethargic
• Monitor potassium: 3.1 Electrolytes: potassium 3.1, sodium 156, • BUN 67
• Fluid overload: edema calcium 8.0 • Creatinine: 8.2
• Peripheral pulses: +2 BL BUN: 67
• Skin was pale and warm to touch, Creatinine: 8.2
membranes dry and cap refill <3
seconds #2
Impaired gas exchange
#5
Ineffective tissue perfusion • Capillary refill <3sec
• BUN: 67 • Hemoglobin 11.4
#8 • Pulse ox: 97%
Anxiety • Creatinine: 8.2
• Sedation vacations • GFR: 7 • Mucous: thick and yellow
• Weaning off sedation • Peripheral edema: • Pale skin color
• Sedation: precedex +3 pitting present in • Monitor heart rate: 57bpm
0.5ml/hr all BL extremities (bradycardia)
• In and out waking up • Blood pressure: • Hypotension: 96/50
caused pt a lot of anxiety 96/50 • Disorientation: lethargic,
and irritability • Muscle twitching: sedated
• Heart rate jumped into no purposeful • Respirations: 22r, normal
90s upon arousal movements rhythm, shallow depth
• Medications used for • Temperature 99.2 • HOB elevated: open
anxiety and irritability: • Capillary refill <3 airways
Haloperidol (1mg PRN), seconds, but slow • Monitor ABGS: 7.47 ph, 42
and Lorazepam (1mg • Electrolytes PCO2, 179 PO2, 31 HCO3:
PRN) • Potassium: 3.1 metabolic alkalosis
• RASS scale: pt would go • Glucose: 266 • CxR: 10/18 atherosclerotic
between -1 to +2 during • Weight: 120kg disease, R atelectasis, fat
weaning period infiltration liver,
cholelithiasis, cardiomegaly
• CxR: 10/22 ETT 4cm
above carina. R Int. Jugular
catheter is within superior
vena cava
P. Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002.
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Problem #1: Ineffective breathing pattern related to mechanical ventilation

General Goal: Patient will maintain effective breathing pattern with normal respirations and depth

Predicted Behavioral Outcome Objective (s): The patient will maintain an O2 sat of >95% on my day of care.

Nursing Interventions Patient Responses

1. Observe pt breathing pattern 1. Accessory muscle use present

2. Monitor abg’s 2. 7.47 ph, 42 PCO2, 179 PO2, 31
3. Apply oxygenation to promote HCO3: metabolic alkalosis
airway 3. rate 16, FiO2 35, TV 500, PEEP 5
4. Suction secretions 4. Thick, yellow secretions
5. Reposition the patient 5. Wedges and maintaining HOB
6. Listen to breath sounds elevated to promote breathing
6. Diminished, crackles
Evaluation of outcome objectives: The outcome was met as evidenced by and o2 sat consistently greater than
>97% on my day of care.

Problem #2: Impaired gas exchange as evidenced by abnormal ABG’s and metabolic alkalosis
General Goal: Patient demonstrates adequate ventilation and oxygenation of tissue

Predicted Behavioral Outcome Objective (s): The patient will have a decreased CO2 value on their ABGs on
the day of care.

Nursing Interventions Patient Responses

1. Continuous assessment of O2 saturation 1. Maintained o2 sat above 97%

2. Monitor for signs of atelectasis 2. Crackles, diminished breath sounds
3. Monitor ABG results 3. PH 7.47 CO2 42 PO2 179 HCO3 31
4. Monitor the effects of sedation and
Analgesics on pt respiratory pattern 4. Sedation did not decrease rr or o2 sat
5. Keep HOB elevated at 45 degrees 5. Keep lungs open, promote airflow
6. Monitor heart rate and blood pressure 6. HR 57 BP 96/50
7. Monitor chest x-rays 7. Cardiomegaly present
8. Suction as needed 8. Thick, yellow secretions removed
Evaluation of outcome objectives: The objective was met, as evidenced by a CO2 of 44 on 10/17 and then an
improved CO2 of 42 on my day of care.

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

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Problem #3: Ineffective airway clearance related to inability to clear own secretions d/t mechanical vent
General Goal: Patient will maintain a clear airway all shift

Predicted Behavioral Outcome Objective (s): The patient will have clear breath sounds and decreased
secretions on my day of care.

oncare.
Nursing Interventions Patient Responses

1. Assess breath and lung sounds 1. Crackles, diminished sounds

2. Suction as needed 2. Thick, yellow secretions
3. Monitor O2 saturation 3. O2 sat remained >97%
4. Monitor vent for high pressure alarm 4. Indicates need for pt suctioning
5. Elevate HOB 45 degrees 5. Promotes flow of secretions
and prevent aspiration
6. Monitor chest x-ray results 6. Cardiomegaly
7. Assess for signs of dehydration 7. Skin turgor elastic, but dry mucous
membranes- indicates dehydration
8. Provide oral care Q4hrs 8. Oral care provided Q4hrs
Evaluation of outcome objectives: The objective was not met as evidenced by crackles upon auscultation and
thick, yellow secretions still present upon suctioning on my day of care.

Problem #4: Decreased cardiac output related to hypotension

General Goal: Patient will show adequate cardiac output as evidenced by stable vital signs.
Predicted Behavioral Outcome Objective (s): The patient will have increased blood pressure on my day of
care.

Nursing Interventions Patient Responses

1. Assess BP due to hypotension 1. BP improved to 99/52

2. Monitor Pulses 2. +2 radial, pedal and post tibial pulses
3. Review Hct and Hgb 3. Hgb 11.4 Hct 37.1 (low)
4. Assess for edema 4. 3+ pitting edema B/L LE
5. Phenylephrine drip 8.1mL/hr 5. BP increased and is improving
6. Monitor ABG’s 6. 7.47 ph, 42 PCO2, 179 PO2, 31
7. Monitor electrolytes 7. Na 156, K 3.1, Ca 8.0
8. Review ecg strips 8. Sinus rhythm
Evaluation of outcome objectives: The patient’s blood pressure increased from the lowest of 72/60 to 99/52,
which is an overall improvement on my day of care.

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

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Problem #5: Ineffective tissue perfusion related to artery diseases and multi-organ distress.
General Goal: Patient will maintain tissue perfusion to all organs
Predicted Behavioral Outcome Objective (s): The patient will have normal pulses, cap refill and appropriate
color to demonstrate adequate tissue perfusion.

Nursing Interventions Patient Responses

1. Assess capillary refill 1. Capillary refill <3seconds

2. Monitor O2 sat 2. O2 97%
3. Monitor hemoglobin and hematocrit 3. Hgb 11.4 Hct 37.1 (low)
4. Monitor ABG’s 4. PH 7.47 CO2 42 PO2 179 HCO3 31
5. Assess peripheral pulses 5. +2 radial, pedal and post tibial pulses
6. Neuro checks Q1hr 6. GSC: 9 lethargic and sedated
7. Assess for mottling 7. No mottling present on any limbs
8. Skin assessment 8. Pallor, warm, dry mucous membranes
Evaluation of outcome objectives: Goal not met. Patient has trouble circulating oxygen throughout body and
has pale skin color, along with dry membranes on my day of care.

Problem #6: Impaired electrolyte imbalance due to renal failure: causing impaired BUN and Cr.
General Goal: Patient labs will improve by the end of shift
Predicted Behavioral Outcome Objective (s): The patient will have improved sodium, potassium, BUN and
creatinine by the end of my shift.

on the day of care.

Nursing Interventions Patient Responses

1. Running free water at 250ml/hr 1. Patient lab values- like Na improved

2. Monitor urine output Q1hr 2. Patient had 1100cc output in 5 hours
3. Monitor pulse, BP and RR Q1hr 3. 57bpm 97/52 22rr
4. Monitor for worsening edema 4. 3+ pitting edema B/L LE
5. Monitor BUN and creatinine 5. BUN 21, creatinine 2.8
6. Daily weights 6. 10/16 119.2kg 10/17 120kg
7. Auscultate heart sounds 7. No arrhythmias present
8. Monitor cardiac rhythm 8. Sinus rhythm on the monitor
Evaluation of outcome objectives: The predicted behavior outcome was met as evidenced by the following
improved lab values: sodium 156, potassium 3.1, BUN 21, creatinine 2.8 on my day of care.

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

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Problem #7: Fluid volume excess related to renal failure

General Goal: Patient will maintain a normal fluid balance
Predicted Behavioral Outcome Objective (s): The patient will maintain their weight and have adequate urine
output on my day of care.

Nursing Interventions Patient Responses

1. Monitor output via foley 1. 1100cc

2. Daily weights 2. 10/23 119.2kg; 10/24 120kg
3. Lung sounds 3. Crackles, diminished
4. Assess for edema 4. B/L lower ext. +2 pitting edema
5. Provide oral care 5. Suctioned and swabbed at 7a and 9a
6. Monitor Cr and BUN 6. BUN 21, creatinine 2.8
7. Assess LOC 7. Sedated and lethargic: A&O x0
Evaluation of outcome objectives: Pt. maintained a normal weight, no excess gain or loss, as well as
adequate urine output of 1100cc on my day of care.

Problem #8: Anxiety related to weaning off of mechanical ventilation

General Goal: Patient will demonstrate a calm affect when doing weaning trials
Predicted Behavioral Outcome Objective (s): The patient will show decreased anxiety when weaning off of
sedation and maintain a normal heart rate.

Nursing Interventions Patient Responses

1. Monitor heart rate 1. Heart rate 57bpm

2. Observe pt reactions and responses 2. agitated, pulling at lines and flailing
3. Administer Lorazepam 1mg PRN 3. Given to calm pt/decrease anxiety
4. Identify what triggers pt anxiety 4. Pt increasingly anxious with weaning
5. Monitor O2 sat 5. Maintained above 97% (A/C vent)
6. Provide comfort measures 6. Provided warm blankets to help calm
7. Explain everything being done to pt 7. To keep pt in the loop and help
decrease anxiety with measures taken
Evaluation of outcome objectives: Goal not met. Pt still had increasing anxiety with weaning trial, even after
lorazepam given. Anxiety was not able to be decreased on my day of care.

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