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
Basic Pathophysiology
mandatory of major DX: Pneumonia is an acute bacterial or viral infection that causes inflammation of the lung
ventilation (SIMV).
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
(6th ed.). St. Louis: Mosby Elsevier.
81 year old,
Caucasian female,
NSG DX #1 admitting diagnosis is
pneumonia and
Impaired gas exchange
respiratory failure.
related to altered oxygen
Patient is currently in
supply and alveolar-capillary NSG DX #2
critical condition in
membrane changes
medical ICU in strict
secondary to inflammatory Impaired verbal
contact precautions
process in the lungs as communication related
due to testing
evidenced by bilateral course to tracheal intubation as
positive for MRSA and
lung sounds with rales, evidenced by patient
Klebsiella in the
restlessness, and abnormal unable to speak clearly.
blood. Patient is on
chest x-ray showing bilateral
tracheal intubation
pleural effusion and
with synchronized
atelectasis.
intermittent
mandatory ventilation
Assessment related to (SIMV).
 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,
atelectasis, dry mucous
membranes and poor skin
turgor. V/S: T 98.2, BP
113/60, HR 59, RR 16,
O2Sat 100% at Fi02 of
35%.
Relevant Labs and Tests
Chest x-ray showed
consolidation at left base with
atelectasis in the right mid-
upper lung field. Hgb 11.5
(low, less O2 in blood), RBC
3.61 (low, anemia), WBC 11.29
(high, possible infection
brewing).
Relevant Meds:
1. Albuterol (Dose: 0.2083
mg = 0.25 ml,
Bronchodilator to control
and open airway)
2. Colistimethate (Dose:
75 mg=0.5 vial, antibiotic
nebulizer prevents
repiratory tract infections)
3. Fi02 at 35% for 100%
O2Sat
Theresa Mendoza
NSG DX #1: Impaired gas exchange
Critical Care Concept Map 2
related to altered oxygen supply and Spring 2011, February 16, 2011
alveolar-capillary membrane changes
secondary to inflammatory process in
the lungs as evidenced by bilateral
course lung sounds with rales, Outcome
restlessness, and abnormal chest x- Parameters
ray showing bilateral pleural effusion
and atelectasis. 1. Patient’s mental
status and vital
signs will remain
WDL or baseline
during shift.
2. O2Sat levels
Interventions & Rationales
Assess and document patient’s remain at 100%
respiratory rate, pattern, effort and during shift.
depth; breath sounds; sputum; and
assess lung sounds for adventitious 3. Respiratory
sounds every four hours and compare meds safely
with baseline. Monitor patient’s vital administered as
signs, blood pressure, temperature, ordered.
heart rate and oxygen saturation
every hour and compare with
baseline. The nurse must monitor
any signs or symptoms of possible
airway obstruction, infection, fever Evaluation
and hypoxia and further damage of
airway. 1. Outcome met, vital
Maintain SIMV at a rate of 12 with signs and mental status
FiO2 at 35% for 100% oxygen remained WDL during
saturation until further orders. O2Sat shift.
rates must be kept at acceptable safe
levels to avoid hypoxemia and 2. Outcome met, O2Sat
increase gas exchange. levels remained at 100%
Safely administer respiratory during shift.
medications as prescribed and/or
monitor that respiratory therapy 3. Outcome met,
administers all prescribed treatments. respiratory meds safely
administered as order
by respiratory therapist.
 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
Assessment unable to speak clearly.
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,
however she was Interventions & Rationales
2. During shift, nurse
Assess cause of impaired
unable to speak. will communicate with
communication. By assessing the
cause nurse can properly develop a patient helping patient
customized plan of care that develop compensatory
Relevant Labs incorporates communication skills methods for
and Tests the patient can use, given the communication.
patient’s disability.
When communicating with the 3. By end of shift,
N/A
patient, face the patient, make patient will feel less
direct eye contact, speaking in a
frustrated.
clear and normal tone of voice.
This will help the patient develop
compensatory methods, for
example, such as lip reading or Evaluation
Relevant Meds
hand gestures, and may assist with
1 & 2: Nurse helped patient
1. Haloperidol (Dose: the communication.
Provide continuous reassurance to by asking her to shake her
1 mg=0.2ml, for patient, acknowledge her head yes or no to questions.
frustration and be alert to It appeared that this helped
agitation) nonverbal messages. These the patient feel less
actions will help decrease frustrated. Outcome met.
2. Midazolam (Dose:
frustration and feelings of isolation.
2mg=2ml, for 3: Outcome partially met,
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 patient’s 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 patient’s 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 patient’s 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
patient’s 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.