Assessment and Concept Map Care Plan

For

Critical Care Patient

Mackenzie Goodin

James and Coralie School of Nursing, Youngstown State University

NURS 4840

Dr. Cynthia Sheilds

November 23, 2021

 Critical Care Patient Case Study
Student: Mackenzie Goodin
Date of Care: 11/9/21

Pt’s Initials: R.S. Rm No.3805 Age: 48 Sex: Male Date admitted: 10/14/21
DNR status: Full

Allergies: PCN, Vicodin(hydrocodone-acetaminophen) Height:6’3” Weight:

365lbs Isolation type: none

Diagnosis(es): Hemorrhage Hypovolemic Shock secondary to Acute GI bleed from cariceal

bleed.

Reason for Admission/Events Leading to Current Hospitalization and reason in unit for >2
days (if appropriate): Pt. was vomiting blood on the night of 11/13, due to esophageal
varices bursting. EMS was called on 11/14 due to unresponsiveness of patient found by
sister, GCS upon arrival was 7. Pt. has history of alcoholic cirrhosis and was getting
paracentesis once a week to help drain fluid from ascites.

Pertinent History of Illness/Surgery:

Chronic liver failure due to alcoholic cirrhosis. Paracentesis starting 8/26/21, right side
10,050 cc straw colored fluid. Emergent surgery 11/14/21 d/t GI bleed, secondary to portal
HTN. EGD to control hemorrhage + laparotomy exploratory

Day of Care:
T: 36.1
BP: 127/35
MAP:58
RR: 24
HR: 105
SpO2: 100%

Oxygenation:
Vent Settings:
Mode: A/C
Rate: 24
FiO2: 100%
TV: 600mL
Peep: 12.
Pertinent Subjective and objective data for the following:
Health Maintenance (Use of Alcohol, Tobacco, Drugs):
History of alcohol use.

Activity/Exercise: Self Care Ability (eating, bathing, transferring, activity tolerance):

UTA to assess activity/exercise, was not alert/arousable, pt. had ETT and GCS of 4.

Cognitive-Perceptual ((mental status, ability to communicate, language barriers,

comprehension, anxiety, interactive skills, hearing, vision, memory): UTA ETT

Role Relationship (marital status, occupation, employment status, support system, family
concerns): Son at home 16 year old.

Value/Belief (religion, spiritual needs): Family needs of coping with diagnosis.

IV Drips

Medication Concentration Rate Site Line

Vasopressin 20 units 12mL/hour CVC Triple Rt. Femoral
dextrose 5% Lumen
100mL
Calcium Chloride 8,000mg in 40mL/hour CVC Triple Rt. Femoral
sodium Lumen (distal)
chloride 0.9%
Norepinephrine 16mg in 2-100 mcg/min CVC Triple Rt. Femoral
(levophed) dextrose 5% 1.9-93.8 mL/hr Lumen (medial)
250mL infusion
Octreotide(Sandr 500 mcg in 10mL/hr CVC Triple Rt. Femoral
o statin) sodium chloride Lumen (medial)
0.9% 100mL
infusion
Pantoprazole 80mg in sodium 10mL/hour CVC Triple Rt. Fermoral
(protonix) chloride 0.9% Lumen (distal)
100mL
Prismasate BGK 5000mL 4000mL/hour Dialysis Green line
Sodium Bicarb 150mcg in 150mL/hour Peripheral IV Rt. hand
dextrose 5%
1000mL
24 hr intake: 18260

24 hr output:5224

Pain/Pain Management fentanyl, Versed (prn)

Treatments Protocols
Replace Fluid Loss Administer blood and fluids
Monitor BP Medicate to keep pressures up
Monitor VS (especially temperatures) Cooling blanket for high temps, heating
blanket for low temps.
 alterations in temps can cause pt. to go
into metabolic acidosis
Monitor I+O via CVV Check foley q 1 hour, regulate dialysis

Pathophysiology: Acute GI bleed, due to portal hypertension from chronic liver failure or
alcoholic cirrhosis. The portal hypertension and the extra pressure caused the esophageal
varices to burst.

Nursing Care: Replace fluid volume loss, via blood and normal saline. Monitor blood
pressures, intake and outputs via dialysis, and medicate to keep pressures up, and tissue
perfusion up.

MEDICATIONS

Name Dose Route/How to Reason Pt 2 Common Side

Administer receiving Effects
Calcium 40mL/hour IV/continuous Cardiac Hypercalcemia
Chloride CVC triple arrhythmias/ &
lumen replace electrolyte hypomagnesium
imbalances
primaSATE 4000mL/hour Dialysis Help pull off extra Hypotension +
BGK continuous fluid due to ascites fluid overload

Dialysate
Sodium 150mL/hour IV continuous Help dec NA Gastric
bicarbonate levels & acidotic distention +
levels in pt metabolic
alkalosis
Acetylcysteine 65.6 mL/hour CVC triple Help to decrease Bronchospasms
lumen (left chest congestion + drowsiness
subclavian
distal)
Albumin 50g or IV q8h CVC Hypoalbuminemi Fever &
Human 200mL/hour triple right a pulmonary
femoral edema
(medial)
Thiamine (B- 100MG IV peripheral Thiamine Anaphylaxis &
10 (rt. Hand) replacement cardiovascular
therapy comp.
Problem #1: Hypovolemia d/t blood volume loss, secondary to GI bleed as evidenced by
hematemesis, skin pallor, blood pressure 127/35 and GCS of 3.

General Goal: Replace fluid volume deficit

Predicted Behavioral Outcome Objective(s): reduce signs of shock to help stabilize patients
blood pressure

Nursing Strategies: Patient Responses:

1. Assess Vital Signs (BP +temp) 1.monitor for signs of shock

2. Administer blood transfusion 2. RBC increased (3.19)

3. Continuous CVV 3.help to decrease fluid volume overload

4.Administer IV therapy for electrolyte 4. No improvement in foley output

imbalance & fluid loss
5. 0-2mL q 1 hour for 4 hours
5. Monitor foley output q hour
6.Map below 65, indicative of inadequate
6. Monitor MAP tissue perfusion.

Evaluation: Patient remains hemodynamically unstable at this time.

Problem #2 Fatigue r/t decreased ability to transport oxygen secondary to deficient blood
volume.

General Goal: Pt. will demonstrate reduced fatigue by a stable hematocrit and hemoglobin as
well as decreased need for oxygenation on the vent.
Predicted Behavioral Outcome Objective(s): Patient Hbg and Hct will increase to values
within the range and patients oxygenation needs will decrease.
Nursing Strategies: Patient Responses:

1. Monitor patients lab values 1. pt. RBC went from 1.85 to 3.50 and HCT
went from 21.2 to 29.2
2. Administer blood transfusion
2.pt rbc increase to 3.50 after transfusion
3. Monitor vital signs
3. pt. has decreased bp and increased HR due
4. Monitor vent settings to low blood volume

5. No turning patient 4. pt. vent settings are FiO2 of 100% and

Peep of 12.0.
6.Encourgae rest periods
5.will help to dec. pt. stimulation to reserve
o2 for the pt.

6. pt. O2 increases when resting and not

exerting energy

Evaluation: Patient status remains unchanged, RBC were 3.19 which is lower than the range,
HCT was 28.7 also lower than the range and vent settings remained FiO2 at 100% and Peep at
12.
Problem #3: Acute pain r/t compromised stomach lining secondary to gastrointestinal bleed.

General Goal: Patient will show a decrease in pain by decreasing HR, and RR and temp and
show signs of increased comfort.

Predicted Behavioral Outcome Objective(s): Patient will show increased comfort and
decreased pain.

Nursing Strategies: Patient Responses:

1. Use CPOT scale to assess patient pain 1. CPOT demonstrates pain at a 8.

2. Treat with prescribed pain medications 2. Pt. HR remains in the 100s.

3. Heating blanket applied 3. Help to maintain patient temperature and

reduce shivering.
4. Perform an abdominal assessment
4. Pt. stomach shows ascites
5. Patient held NPO
5. Help to reduce GI irritation and facilities
6. Assess pt. status 30 min after medication is healing
administered
6. Pt. status remained the same, no signs of
relief

Evaluation: Patient status and vital signs stayed the same.

Problem #4: Impaired spontaneous ventilation related to metabolic factors as evidenced by
arterial pH less than 7.35

General Goal: Pt. will maintain spontaneous gas exchange resulting in reduced dyspnea,
normal oxygen saturation and normal ABGs withing patient parameters.

Predicted Behavioral Outcome Objective(s): Patient will ventilate effectively with a decrease
in FiO2 and Peep.

Nursing Strategies: Patient Responses:

1. Check correct placement for ET tube 1. Pt. demonstrates bilateral breath sounds
upon placement
2. Maintain pt.s airway clear from secretions
2. Pt. suctioned q 2 hours
3. Maintain pt.s HOB increased to 30 degrees
3. Promotes oxygenation and reduces change
4. Assess AGS as ordered by doctor of aspiration

5. Institute mechanical ventilation with 4. ABGS remain unstable, pH of 7.039,

prescribed settings PCO2 57.4, PO2 204.7 and HCO3 15.5.

6. Administer sedatives (versed) as ordered. 5.FiO2 at 100% and Peep of 12, Rate of 24
with no pt. breaths initiated.

6. Help to decrease clients work of breathing

and facilitate effective gas exchange.

Evaluation: Patient was unable to wean from the parameters at this time.
Problem #5: Excess fluid volume related to compromised regulatory mechanism as evidenced
by edema, ascites, dyspnea, change in mental status and BP changes.

General Goal: Demonstrate fluid volume with balanced I&O, stable weight, vital signs and
absence of edema.

Predicted Behavioral Outcome Objective(s): Patients output will be greater than 2mL in a 4
hour period and albumin and electrolyte values will go back to normal value.

Nursing Strategies: Patient Responses:

1. Measure I&O 1. Pt. foley output remained 0-2mL over a 4

hour period.
2. Assess respiratory status
2. Patient remains stable on ventilator with
3. Measure abdominal growth prescribed settings

4.Monitor serum albumin and electrolytes 3. Pt. shows no change in ascites.

5. Pt. placed on CVV 4.Pt. remains in state of hypoalbuminemia

6. Monitor for cardiac dysrhythmias 5. Pt. on continuous dialysis to help decrease

fluid accumulation

6. No dysrhythmias found. S1+S2 present

Evaluation: No change in patient status at this time.

Problem #6: Excess hematemesis d/t esophagitis varices secondary to cirrhosis of the liver.

General Goal: Stop the bleed and replace lost fluid volume.

Predicted Behavioral Outcome Objective(s): Shock symptoms will decrease, fluid volume
deficit will increase, blood will be replaced.

Nursing Strategies: Patient Responses:

1. Prep pt. for procedure to stop the EV bleed. 1. Pt. unresponsive due to excess fluid deficit

2. Blood transfusions 2. Replace lost blood, helps increase pt. status

3. Fluid replacement 3. Help to stabilize vital signs

4.Monitor for excessive bleeding 4. Pt. has risk to bleed again

5.NG suction 5. Helps to clear pt. airway of old blood

6. Monitor for signs of shock 6.Pt. vitals were temp of 36.1, HR 105, RR,
24, BP 127/35 MAP of 58 Spo2 100%

Evaluation: Pt. is unresponsive, and vitals are unstable. No signs of improvement.