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Theresa Mendoza

Critical Care Concept Map 2


Spring 2011, February 16, 2011

Pt. Demographics: Patient is 81 years old, Caucasian Female, DOB February 9, 1930. She is a resident from a local nursing
home.
Past Hx: Significant medical history includes diabetes, dementia, status post-trachea, hypertension, congestive heart failure, atrial
fibrillation, osteoarthritis, right hip fracture, end-stage COPD, schizophrenia, and anemia.
Present Med Dx: Admitting diagnosis is Pneumonia and respiratory failure with pleural effusion of left and right lungs. Lab tests
showed an increased WBC count. Patient is currently in critical condition in medical intensive care unit in strict contact precautions
due to testing positive for MRSA and Klebsiella in the blood. Patient is on tracheal intubation with synchronized intermittent
mandatory
Basic ventilation (SIMV).
Pathophysiology of major DX: Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung
parenchyma (alveolar spaces and interstitial tissue) causing potential issues such as hypoxemia (Swearingen, 2007). Hypoxemia can
occur as a result of the inflammation if involved lung tissue becomes edematous and air spaces fill with exudates (consolidation), gas
exchange cannot occur, and non-oxygenated blood is shunted into the vascular system (Swearingen, 2007). General signs and
symptoms include cough (productive and nonproductive), fever, pleuritic chest pain, dyspnea, chills, headache, and myalgia. Physical
assessment findings may include restlessness, anxiety, decreased skin turgor and dry mucous membranes secondary to dehydration,
decreased breath sounds, high-pitched and inspiratory crackles (rales) or low-pitched inspiratory crackles caused by airway secretions
(Swearingen, 2007). Abnormal chest x-ray results may present normal physical assessment findings (Swearingen, 2007). Acute
respiratory failure (ARF) develops when the lungs are unable to exchange O2 and CO2 adequately (Swearingen, 2007). Four basic
mechanisms are involved that can lead to development of respiratory failure. First is alveolar hypoventilation, then ventilation-
perfusion mismatch, diffusion disturbances and then right-to-left shunt. Clinical indicators will vary according to underlying disease
process and severity of the failure (Swearingen, 2007).

Reference: Swearingen, P.L. (2007). Manual of medical-surgical nursing care: Nursing interventions and collaborative management (6 th
ed.). St. Louis: Mosby Elsevier.
81 year old,
Caucasian female,
NSG DX #1 admitting diagnosis is
pneumonia and NSG DX #2
Impaired gas exchange
respiratory failure.
related to altered oxygen
Patient is currently in Impaired verbal
supply and alveolar-capillary
critical condition in communication related
membrane changes
medical ICU in strict to tracheal intubation as
secondary to inflammatory
contact precautions evidenced by patient
process in the lungs as
due to testing unable to speak clearly.
evidenced by bilateral course
positive for MRSA and
lung sounds with rales,
Klebsiella in the
restlessness, and abnormal
blood. Patient is on
chest x-ray showing bilateral
tracheal intubation
pleural effusion and
with synchronized
atelectasis.
intermittent
(SIMV).
Theresa Mendoza
Assessment related to
Critical Care Concept Map 2
this ND: Patient is alert Spring 2011, February 16, 2011
NSG DX #1: Impaired gas exchange
and oriented x 2,
related to altered oxygen supply and
cooperative, but a bit
alveolar-capillary membrane changes
agitated due to impaired
secondary to inflammatory process in
communication, bilateral
the lungs as evidenced by bilateral
diminished and course
course lung sounds with rales, Outcome
lung sounds with rales
restlessness, and abnormal chest x- Parameters
upon inspiration, chest x-
ray showing bilateral pleural effusion
ray showed bilateral
and atelectasis. 1. Patients mental
pleural effusion,
status and vital
atelectasis, dry mucous
signs will remain
membranes and poor skin
WDL or baseline
turgor. V/S: T 98.2, BP
during shift.
113/60, HR 59, RR 16,
Interventions & Rationales
O2Sat 100%
Relevant at and
Labs Fi02Tests
of 2. O2Sat levels
Assess and document patients
35%.
Chest x-ray showed respiratory rate, pattern, effort and remain at 100%
consolidation at left base with depth; breath sounds; sputum; and during shift.
atelectasis in the right mid- assess lung sounds for adventitious
upper lung field. Hgb 11.5 sounds every four hours and compare 3. Respiratory
(low, less O2 in blood), RBC with baseline. Monitor patients vital meds safely
3.61 (low, anemia), WBC 11.29 signs, blood pressure, temperature, administered as
(high, possible infection heart rate and oxygen saturation
ordered.
brewing). every hour and compare with
baseline. The nurse must monitor
any signs or symptoms of possible
Evaluation
airway obstruction, infection, fever
and hypoxia and further damage of 1. Outcome met, vital
Relevant Meds: airway. signs and mental
1. Albuterol (Dose: 0.2083 Maintain SIMV at a rate of 12 with status remained WDL
FiO2 at 35% for 100% oxygen
during shift.
mg = 0.25 ml, saturation until further orders. O2Sat
rates must be kept at acceptable safe 2. Outcome met,
Bronchodilator to control levels to avoid hypoxemia and O2Sat levels remained
increase gas exchange.
and open airway) at 100% during shift.
Safely administer respiratory
2. Colistimethate (Dose: medications as prescribed and/or 3. Outcome met,
monitor that respiratory therapy respiratory meds
75 mg=0.5 vial, antibiotic administers all prescribed treatments. safely administered as
nebulizer prevents order by respiratory
therapist.
repiratory tract infections)

3. Fi02 at 35% for 100%


O2Sat
Theresa Mendoza
Critical Care Concept Map 2
Spring 2011, February 16, 2011
NSG DX # 2: Impaired verbal
communication related to tracheal
intubation as evidenced by patient
unable to speak clearly.
Assessment
related to this
Outcome Parameters
ND
1. During shift, nurse
During
will help patient with
assessment
frustrations related to
patient was
communication
asked if she was
barriers.
in any pain, Interventions & Rationales
however she was Assess cause of impaired 2. During shift, nurse
unable to speak. communication. By assessing the will communicate with
cause nurse can properly develop a patient helping patient
customized plan of care that
develop compensatory
Relevant Labs incorporates communication skills
the patient can use, given the methods for
and Tests communication.
patients disability.
When communicating with the
N/A patient, face the patient, make 3. By end of shift,
direct eye contact, speaking in a patient will feel less
clear and normal tone of voice. frustrated.
This will help the patient develop
compensatory methods, for
example, such as lip reading or
hand gestures, and may assist with Evaluation
the communication. 1 & 2: Nurse helped
Relevant Meds
Provide continuous reassurance to
patient by asking her to
1. Haloperidol (Dose: patient, acknowledge her
frustration and be alert to shake her head yes or no
1 mg=0.2ml, for nonverbal messages. These to questions. It appeared
actions will help decrease that this helped the
agitation) frustration and feelings of isolation. patient feel less frustrated.
2. Midazolam (Dose: Outcome met.
3: Outcome partially met,
2mg=2ml, for
when asked if patient felt
agitation) okay, patient shook her
head yes.
Theresa Mendoza
Critical Care Concept Map 2
Spring 2011, February 16, 2011

Synthesis and discussion of Patient, problems, care, and evaluation

S: Received at bedside 81 years old, Caucasian Female, DOB February 9, 1930. She is a resident
from a local nursing home. Admitted at ED on 2-4-11, NKA.
B: Patient was brought to ED on 2-4-11 with admitting diagnosis of respiratory failure and
pneumonia. Upon further testing, chest x-ray showed bilateral pleural effusion and increased
WBC count. Significant medical history includes diabetes, dementia, status post-trachea,
hypertension, congestive heart failure, atrial fibrillation, osteoarthritis, right hip fracture, end-
stage COPD, schizophrenia, and anemia. Patient is currently in critical condition in medical ICU
in strict contact precautions due to testing positive for MRSA and Klebsiella in the blood.
Patient is on tracheal intubation with synchronized intermittent mandatory ventilation (SIMV).
A: Assessment findings are V/S: T 98.2, BP 113/60, HR 59, RR 16, O2Sat 100% which is
maintained with Fi02 of 35%. Patient is alert and oriented x 2, cooperative, but a bit agitated
due to impaired communication, bilateral diminished and course lung sounds with rales upon
inspiration, chest x-ray showed bilateral pleural effusion and atelectasis. Other important
assessment findings are dry mucous membranes and poor skin turgor. Heart sounds irregular,
however upper and lower peripheral pulse strengths felt normal and good. Bowel sounds
present in all quadrants. Skin intact except for left foot there is a 1 inch skin tear on the top of
the foot. Urinary output is WDL and patient has Foley catheter. Lasix or diuretics have not
been ordered for patient at this time.
R: Recommendation for plan of care is to maintain patients O2Sat levels by monitoring that FiO2
of 35% is adequate O2 therapy level. If O2Sat levels fall below baseline or WDL, report to
provider. Maintain patient safety, making sure all side rails are up and bed is in lowest
position, maintain strict contact precautions at all times by monitoring all visitors and staff
who enter patients room wear proper covering and gloves, monitor vitals hourly that they are
WDL, provide oral care to prevent ventilator acquired pneumonia every four hours, turn
patient every two hours to prevent skin breakdown, monitor patients secretion and provide
suctioning through trachea tube as needed, routinely check all tubing that they are all intact,
and maintain HOB at 30% to prevent aspiration and promote airway clearance. To help ease
patients agitation, communication should be consistent. Provide continuous reassurance to
Theresa Mendoza
Critical Care Concept Map 2
Spring 2011, February 16, 2011

patient, acknowledge her frustration and be alert to nonverbal messages. These actions will
help decrease frustration and feelings of isolation.