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Janessa Martinelli
11/16/2023
Dr. Laura Calcagni
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Failure to ventilate due to apnea:
Concept Map
Ventilator A/C mode
No breaths above vent
setting 2
Tachypnea
Decreased cardiac output due to
Tachycardia cardiac arrest:
Bilateral diminished breath 48/37 BP upon arrival
sounds
93.9 temp upon arrival
Mixed acidosis- 3
Weak peripheral pulses
o Decreased pH
Vasopressin
o Increased PCO2 Inadequate cerebral
Increased troponin- 380 perfusion due to cardiac
o Decreased HCO3
Increased CK- 61,530 arrest:
Chest x-ray shows bilateral
Increased lactate- 9.2 GCS score- 3
pneumonia
Cool extremities Positive Babinski
Increased lactate- 9.2
Decreased urine output Negative
Tachycardia oculocephalic
Metabolic acidosis Pinpoint
Family role strain due to Capillary refill >3 sec nonreactive pupils
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inability to make health GI bleed Eye swelling
decisions: Negative corneal
Pt. is a prisoner. reflex
The state is pts legal Negative cough
guardian. Reason For Needing Health Negative gag
Pt had conflicting thoughts Care Decerebrate
about organ donation. Medical Diagnosis:
posturing
Pt. is brain dead. Acute Respiratory Failure,
Cardiac Arrest, and Anoxic
Pt’s organ is healthy. Brain Injury
State can decide when family
can visit.
Prison guards are always 4
present. 5
Impaired kidney function due to
Fluid volume deficit: decreased perfusion:
6 Drug toxicity due to fentanyl
Decreased pulses Decreased urine output- 90mL
and cannabis use:
Dry mucous membranes in 4 hours
Positive for fentanyl
Tachycardia Elevated ALT- 3,762
Positive for cannabis
Hypotension Elevated AST- 4,547
Loss of consciousness
GI bleed Elevated creatinine- 5.2
Hypoxic
NPO Cardiac arrest
Hypotensive
Decreased urine output- Decreased pulses
Hypothermic
90mL in 4 hours AKI
Pinpoint pupils
Cap refill > 3 sec Decreased CO
Seizures
Decreased skin turgor Increased BNP- 1,620
Increased sodium- 148 Decreased total protein- 5
Decreased albumin- 3.2 Hypotension
Decreased total protein- 5 Decreased calcium- 1.02
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Problem # 1: Failure to ventilate due to apnea.
General Goal: Patient will initiate breaths above the set rate on the ventilator.
Predicted Behavioral Outcome Objective (s): Patient will initiate more than the set rate of 24
breaths per minute on day of care.
Nursing Interventions: Patient Responses:
1) Suction PRN. 1) No secretions present upon suction,
2) HOB at least 30 degrees. SpO2 remained 100%.
3) Monitor continuous SpO2. 2) Patient’s SpO2 was 100%.
4) Listen to lung sounds every 2 3) Patient’s SpO2 was 100% on FiO2 of
hours. 80%.
5) Evaluate daily ABG values. 4) Patient’s lungs sounded clear and
6) Assess capillary refill every 2 diminished bilaterally upon auscultation.
hours. 5) Patient’s ABG on DOC showed mixed
7) Administer Solu Cortef 50 mg IV. acidosis.
8) Assess respiration rate every hour. 6) Patient’s capillary refill was >3 seconds.
7) Patient’s SpO2 was 100%.
8) Patient’s respiratory rate remained at 24
breaths per minute.
Evaluation of outcomes objectives: Goal was not met; Patient did not initiate more than the
set rate of 24 breaths per minute on day on care.
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Problem # 2: Decreased cardiac output.
General Goal: Patient will have stable vital signs.
Predicted Behavioral Outcome Objective (s): Patient will maintain MAP >70, per doctors’
orders, on day of care.
Nursing Interventions: Patient Responses:
1) Monitor blood pressure and MAP 1) Patient’s MAP was between 70-82 on
every hour. DOC.
2) Administer continuous 2) Patient’s MAP was between 70-82 on
epinephrine and titrate. DOC.
3) Administer continuous 3) Patient’s MAP was between 70-82 on
norepinephrine and titrate. DOC.
4) Administer continuous lactated 4) Patient’s MAP was between 70-82 on
ringers at 50mL per hour. DOC.
5) Evaluate daily cardiac enzyme lab 5) Patient’s troponin was 380 on DOC.
values. Patient’s CK was 61,530 on DOC.
6) Assess cardiac rhythm at 0800. 6) Patient’s heart rhythm was sinus
7) Assess patient capillary refill tachycardia at 0800.
every 2 hours. 7) Patient’s capillary refill was >3 seconds.
8) Assess patient heart rate every 8) Patient’s heart rate was between 115-
hour. 116 on DOC.
Evaluation of outcomes objectives: Goal met; Patient’s MAP remained >70, per doctors’
orders, on day of care.
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Problem # 3: Inadequate cerebral perfusion.
General Goal: Patient will have improved cerebral perfusion.
Predicted Behavioral Outcome Objective (s): Patient will respond to stimuli on day of care.
Nursing Interventions: Patient Responses:
1) Apply nail bed pressure. 1) Patient had decerebrate posturing in
2) Assess for Babinski reflex. response.
3) Assess for oculocephalic reflex. 2) Patient had a positive Babinski reflex.
4) Assess patient’s pupillary 3) Patient had a negative oculocephalic
response to penlight. reflex. Patient’s eyes remained fixed.
5) Assess for a gag reflex. 4) Patient’s pupils remained pinpoint and
6) Assess continuous BIS motor nonreactive to penlight.
values. 5) Patient had a negative gag reflex.
7) Assess for edema every 2 hours. 6) Patient’s BIS monitor revealed 96 on
8) Assess for corneal reflex. DOC.
7) Patient’s eyes appeared swollen on
DOC.
8) Patient had a negative corneal reflex on
DOC.
Evaluation of outcomes objectives: Goal not met; Patient did not respond to any stimuli
applied to him on day of care.
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Problem # 4: Decreased kidney function due to decreased perfusion.
General Goal: Patient will have normal kidney function.
Predicted Behavioral Outcome Objective (s): Patient will urinate 30mL per hour on day of
care.
Nursing Interventions: Patient Responses:
1) Assess daily creatinine and BUN 1) Patient’s creatinine was 5.2 on DOC.
level. Patient’s BUN was 29 on DOC.
2) Assess daily albumin level. 2) Patient’s albumin was 3.2 on DOC.
3) Assess hourly urine output. 3) Patient’s urine output was 90mL on
4) Assess hourly MAP. DOC.
5) Administer continuous 4) Patient’s MAP was between 70-82 on
epinephrine and titrate. DOC.
6) Administer continuous 5) Patient’s MAP was between 70-82 on
norepinephrine and titrate. DOC.
7) Assess for peripheral edema. 6) Patient’s MAP was between 70-82 on
8) Administer continuous lactated DOC.
ringers 50mL per hour. 7) Patient did not have peripheral edema
present.
8) Patient’s MAP was between 70-82 on
DOC.
Evaluation of outcomes objectives: Goal not met: Patient only urinated 90mL in 4 hours on
day of care.
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Problem # 5: Fluid volume deficit.
General Goal: Restore fluid and electrolyte balance.
Predicted Behavioral Outcome Objective (s): Patient’s sodium will decrease from prior days
lab value of 149.
Nursing Interventions: Patient Responses:
1) Assess daily sodium level. 1) Patient’s sodium level was 148 on DOC.
2) Administer continuous lactated 2) Patient’s MAP was between 70-82 on
ringers at 50mL per hour. DOC.
3) Assess daily urine output. 3) Patient’s urine output was 90mL in 4
4) Assess daily intake. hours on DOC.
5) Assess skin turgur. 4) Patient’s intake was 1,386.3 mL on
6) Assess patient’s peripheral pulses. DOC.
7) Monitor hourly MAP. 5) Patient’s skin turgur was poor.
8) Assess capillary refill every 2 6) Patient’s peripheral pulses were 1+
hours. bilaterally.
7) Patient’s MAP was between 70-82 on
DOC.
8) Patient’s capillary refill was > 3 seconds
on DOC.
Evaluation of outcomes objectives: Goal met; Patient’s sodium level was 148 on day of care.
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Problem # 6: Drug toxicity due to fentanyl and cannabis use.
General Goal: Restore liver function due to drug toxicity.
Predicted Behavioral Outcome Objective (s): Patient’s ALT will decrease from prior days
lab value of 4,219.
Nursing Interventions: Patient Responses:
1) Assess patient’s drug toxicity 1) Patient was positive for fentanyl and
level. cannabis upon admission.
2) Assess patient’s ALT and AST 2) Patient’s ALT level was 3,762 on DOC.
lab values on DOC. Patient’s AST level was 4,547 on DOC.
3) Assess patient’s ammonia lab 3) Patient’s ammonia level was 100 upon
value upon admission. admission.
4) Monitor for seizures every hour. 4) Patient was seizing every hour.
5) Assess MAP every hour. 5) Patient’s ALT level 3,762 on DOC.
6) Administer Zosyn 25mL/hr. 6) Patient’s MAP was between 70-82 on
7) Administer continuous DOC.
epinephrine and titrate. 7) Patient’s MAP was between 70-82 on
8) Administer continuous DOC.
norepinephrine and titrate. 8) Patient’s MAP was between 70-82 on
DOC.
Evaluation of outcomes objectives: Goal met; Patient’s ALT decreased from 4,219 from the
previous day, to 3,762 on day of care.
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Problem # 7: Family role strain due to inability to make health care decisions.
General Goal: Family will have the ability to cope with situation.
Predicted Behavioral Outcome Objective (s): Family will share feelings about the inability to
make health care decisions on day of care.
Nursing Interventions: Patient Responses:
1) Explain patient condition to the 1) Family not present.
family. 2) Family not present.
2) Be open to families concerns and 3) Family not present.
questions. 4) Family not present.
3) Try to provide privacy with 5) Family not present.
patient’s guards present. 6) Family not present.
4) Provide emotional support due to
patient brain death.
5) Provide a professional manner
when communicating in a
difficult situation.
6) Provide education and resources.
Evaluation of outcomes objectives: Goal not met; Family was not present to share feelings
about the inability to make health care decisions on day of care.
