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Marissa Wiesen

Critical Care Concept Map

NURS 4840: Complex Care

April 13, 2021

JC 58 y.o. male admitted 3/7

Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement on 3/9

Overview of patient:

Full code with no known allergies

Pt present to the ED on 3/7 with chest heaviness onset the last couple days. SOB and pain radiating to the left arm which
is severe and worsening. Pt states halfway through his workout his lungs were burning. Also, low back pain onset 1 week
ago.

History: obesity, hyperlipidemia, metabolic syndrome, COVID + October 2020, acute coronary syndrome, small
subendocardial MI, severe aortic stenosis,

Family history of heart disease and coronary artery disease.

Post op pt reports lack of sensation to bottom of left foot that impairs ambulation
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#1 Impaired cardiac tissue perfusion /

decreased cardiac output

#2 Impaired gas exchange #3 Knowledge deficit

Reason for Needing

Health Care:

Post coronary artery

bypass graft (CABG) x 3
and post aortic valve
replacement
#4 Inadequate kidney perfusion #5 Deficient fluid volume
Key assessment:

1. Cardiac
2. Peripheral
vascular
3. Integumentary

#6 Impaired peripheral tissue perfusion / #8 Impaired skin integrity

impaired sensation

#7 Constipation
Key Problem #1: Key Problem #2: Key Problem #3:
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Impaired cardiac tissue Impaired gas exchange Knowledge deficit
perfusion / decreased cardiac
Supporting Clinical Patient Data: Supporting Clinical Patient Data:
output
1. ABGs showing compensated 1. Patient had myocardial
Supporting Clinical Patient Data:
metabolic alkalosis r/ventilation infarction.
1. EKG shows NSTEMI 2. Need for ventilation post op. pt was 2. Not following healthy
2. Cardiac catherization extubated 3/10 diet
shows blockages: 95% 3. SpO2 = 92% and 93%. Normal but low 3. Patient report chest
LCA, 85-90% RCA, 50% normal heaviness with onset last
mid stenosis and 75-85% 4. Mediastinal chest tube couple days and did not
proximal stenosis of LADC 5. Post extubation day 5, breath sounds come to ED
3. Troponin .361  .499 clear, RR unlabored and spontaneous 4. Pain in lower back onset
4. Chest pain radiating to 1 week ago and did not
left arm come to ED
5. SOB on admission
6. Bilateral lower extremity
edema Key Problem #5:

Reason for Needing Health Care: Deficient fluid volume

Key Problem #4: Post coronary artery bypass graft Supporting Clinical Patient Data:
Inadequate kidney perfusion (CABG) x 3 and post aortic valve
1. Na = 112 (dehydration)
replacement
2. RBC = 4.79 on admission.
Supporting Clinical Patient Data:
Key assessment: Post-surgery RBC = 3.28
1. BUN 27 3. Hgb = 15.1 on admission.
2. Creatinine is normal 1. Cardiac Post-surgery Hgb = 9.3
3. NSTEMI 2. Peripheral vascular 4. Hct = 44.5 on admission.
4. Bilateral lower extremity 3. Integumentary Post-surgery Hct = 30.1
edema 5. Dry skin, oral mucosa

Key Problem #6: Key problem #8:

Key Problem #7: Impaired skin integrity
Impaired peripheral tissues
perfusion / impaired sensation Constipation Key assessment:
Supporting Clinical Patient Data: Supporting Clinical Patient Data: 1. Post-operation midline
1. Post-operation pt reports 1. Hypoactive bowel sounds incision
numbness to bottom of 2. Decrease oral intake 2. Double mediastinal chest
left foot 3. Alteration in diet from home tube (taken out 3/16)
2. Impaired ambulation 4. Use of multiple medications such as a. No redness,
3. Pt is on Neurontin stool softeners, milk of magnesia, etc. drainage
on an PRN basis b. Covered with 4x4
5. Post-surgery
6. Abdomen soft and round
7. BM on 3/16. No need for GI
medications for constipation during
shift
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #1:

 Impaired cardiac tissue perfusion / decreased cardiac output r/y myocardial infarction

General Goal:

 Patient will maintain cardiac tissues perfusion and cardiac output.

Predicted Behavioral Outcome Objective(s):

 The patient will show no signs or symptoms of decrease cardiac perfusion such as chest pain or shortness of
breath and maintain MAP about 70 on the day of care.

Nursing Interventions:

1. Monitor MAP, vitals

2. Assess labs such as troponin, INR, PT, and PTT
3. Assess EKG results
4. Assess cardiac catheterization results
5. Administer antiplatelets medications such as aspirin
6. Administer blood pressure medication – beta blocker – metoprolol
7. Administer medication for hyperlipidemia (statin) – atorvastatin
8. Prepare for angioplasty with stent placement and valve replacement / provide education pre- and post-surgery
9. Provide education about proper cardiac diet

Patient Responses:

1. MAP = 72. HR = 85. BP = 115/57. RR = 25. SpO2 = 92 on room air

2. Troponin = .361  .499 / INR = 1.8  1.7 / PT = 19.5  18.8 / PTT = 50.4  48.2
3. EKG results show NSTEMI
4. Cardiac cath shows blockages: 95% LCA, 85-90% RCA, 50% mid stenosis and 75-85% proximal stenosis of LADC
5. No signs/ symptoms r/t aspirin administration
6. Blood pressure = 115/57. Patient does not report as side effects from metoprolol medication
7. Patient does not report as side effects from atorvastatin medication
8. Patient underwent CABG x3 and aortic valve replacement on 3/9. On day of care, patient reported that pain is
under control. Patient walked in hallway with assistance.
9. Patient understand dietary restriction of low salt diet and low cholesterol diet.
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #2:

 Impaired gas exchange r/t need for ventilation post-surgery for 3 days

General Goal:

 Patient will have good gas exchange.

Predicted Behavioral Outcome Objective(s):

 The patient will maintain oxygen saturation above 92% on the day of care.

Nursing Interventions:

1. Elevate head of bed to above 45 degrees and encourage deep breathing

2. Monitor SpO2 and administer oxygen as needed
3. Monitor ABGs, H&H
4. Monitor respiratory rate, depth, and effort. Also, for use of accessory muscles, nasal flaring, and abnormal
breath sounds/patterns.
5. Educate on purpose of incentive spirometer and how to use it
6. Monitor behavior and mental status for any changes
7. Assess for cyanosis of skin and nail beds, color of oral mucosa and tongue
8. Encourage and assist with ambulation

Patient Responses:

1. Semi fowlers positions and deep breathing increases patient’s SpO2 saturation
2. SpO2 was above 92% with all vital assessments
3. ABGs show metabolic alkalosis. pH=7.44, CO2=46.2, HCO3=31 and Hgb=9.3, Hct=30.1 post-surgery
4. Respiratory rate is regular and unlabored without the use of accessory muscles, nasal flaring. Breath sounds are
clear with not abnormal sounds
5. Patient shows understanding of incentive spirometer use. Also, shows demonstration of understanding
6. Patient has no change in behavior or mental status during shift
7. Patient’s extremities are warm, normal in color for ethnicity. Nailbeds are pink with capillary refill less than 3
seconds. Oral mucosa and tongues are pink and moist
8. Patient ambulated in hallway with assistance and no signs/symptoms of respiratory distress or cyanosis
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #3:

 Knowledge deficient r/t myocardial infarction, waiting to seek medical care

General Goal:

 Patient will show adequate knowledge about illness.

Predicted Behavioral Outcome Objective(s):

 The patient will report 3 lifestyles changes that he should make on day of care.

Nursing Interventions:

1. Assess patient desire and ability to learn

2. Assess / education on proper diet. Heart healthy. Limit sodium and cholesterol in diet
3. Assess / education on exercise/activity and importance for healthy lifestyle
4. Assess /education on signs and symptoms of myocardial infarction
5. Education on importance of taking medications for BP and hyperlipidemia
6. Educate about the importance of contacting physician if chest pain, change in anginal pattern, or other
symptoms occur
7. Stress the importance of follow up care and community resources and support groups if needed
8. Reduce risk factors such as smoking cessation, limit alcohol consumptions and obesity

Patient Responses:

1. Patient is able to learn about condition and wants to know about a healthy diet
2. Patient shows understanding on heart healthy diet
3. Patient understands immediate restrictions in regard to his condition post-surgery but also the importance of
active lifestyle in the future
4. Patient now understands the signs and symptoms of myocardial infarction such as chest pain radiating to left
arm, shortness of breath, nausea etc.
5. Patient states that he will continues his prescribed medication upon discharge
6. Patient shows understanding of the importance of seeking medical care if angina symptoms worsen or change in
the future
7. Patient does not show interest in community resources or support groups but agrees to be compliant with
follow up appointments
8. Patient states that he does not smoke but he does socially drinks once in a while.
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #4:

 Inadequate kidney perfusion r/t decrease cardiac output, blood loss during surgery

General Goal:

 Patient will have adequate kidney perfusion.

Predicted Behavioral Outcome Objective(s):

 The patient will void a minimum of 3 times on the day of care.

Nursing Interventions:

1. Encourage fluids of at least 750 during 7 am to 1130 am (our time on the floor)
2. Monitor I&O
3. Monitor labs such as creatinine, BUN, GFR, electrolytes
4. Monitor vitals and MAP for assure good perfusion to the kidneys
5. Assess peripheral pulses for decrease cardiac output
6. Assess fluid balance and weight. Edema. Capillary refill
7. Monitor heart and lung sounds for overload if kidneys cannot excrete the fluids.
8. Administer diuretics per order if needed

Patient Responses:

1. During shift patient drank 1000 ml of fluid

2. During shift patient drank 1000 ml of fluid and voided three times during shift
3. Creatinine = 1.02, BUN = 27, GFR = > 60, K = 3.9, Na = 143, Cl = 112,
4. BP = 115/57, HR = 86, RR = 24, SpO2 = 92, and MAP = 72
5. Peripheral pulse are 2+
6. Patient weight is 87.5 kg. bilateral lower extremity edema and capillary refill is less than 3 seconds
7. Heart has regular rate and rhythm, lung sounds clear with no adventitious sounds
8. No diuretics were needed to be given
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #5:

 Deficient fluid volume r/t blood loss during surgery, not drinking enough fluids in the hospital, being on a
ventilator for 3 days

General Goal:

 Patient will have a balanced fluid volume.

Predicted Behavioral Outcome Objective(s):

 The patient will drink 750 ml from 7 am – 1130 am (the amt of time we are on the floor) on the day of care.

Nursing Interventions:

1. Encourage fluids by mouth and monitor I&O

2. Assess H&H, Na, Cl
3. Assess blood pressure, heart rate, and edema
4. Assess renal function such as BUN, creatinine, GFR
5. Assess urine Q 1 hour for color and clarity, and amount
6. Assess skin for dryness, oral mucosa, skin turgor
7. Monitor for alteration in mental status
8. Monitor for active fluid loss from incision, chest tube drainage, diarrhea, vomiting.

Patient Responses:

1. Patient drank 1000 ml of fluids by mouth and voided 3x during shift.

2. Post-surgery hbg = 9.3, hct = 30.1 d/t blood loss during surgery. post-surgery Na = 143, and Cl = 112 d/t
dehydration.
3. BP = 115/57, HR = 85. Non pitting edema to bilateral lower extremities.
4. Creatinine = 1.02 (normal) and BUN = 27 (slightly elevated d/t fluid volume status) and GRF = > 60.
5. Patient voided 3 x during shift. Urine was clear and yellow.
6. Patient had warm, intact, and elastic skin (except for incision site and drain sites). Oral mucosa was moist and
intact. Skin turgor was elastic with no tenting.
7. Patient had not alteration in mental status. Patient is alert and oriented x3 follows commands and cooperative.
Patient was discharged to rehabilitation facility on day of care.
8. No drainage from incision site. Chest tube had 120 ml but was discontinued on day of care. no diarrhea or
vomiting.
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #6:

 Impaired peripheral tissue perfusion/ impaired sensation r/t decrease cardiac output, blood loss during surgery
o Patient has numbness to left foot

General Goal:

 Patient will have no deficits in sensory perception or tissue perfusion.

Predicted Behavioral Outcome Objective(s):

 The patient will report no numbness or tingling to the bottom of his left foot on the day of care.

Nursing Interventions:

1. Administer gabapentin
2. Assess capillary refill and peripheral pulses, color of skin in affected extremity, cyanosis
3. Assess fluid volume status such as RBCs, H&H d/t decrease cardiac output/ fluid loss from surgery. monitor for
increases each day post-surgery
4. Monitor patient during ambulation for unsteadiness to promote safety. Use assistive devices such as walker
when ambulating
5. Assess for sensation by light touch and painful/sharp touch
6. Assess vital signs and MAP for good perfusion to extremities
7. Monitor changes in mental status d/t decreases perfusion to all organs
8. Promote active and passive range of motion exercises to prevent venous stasis and further compromise
circulation

Patient Responses:

1. Patient has no trouble taking medication but still reports numbness to lower left foot. This is new onset post-
surgery
2. Capillary refill is less than 3 seconds on upper and lower extremities. Pulses are 2+, skin color is appropriate to
ethnicity with no pallor or cyanosis
3. Post-surgery RBCs = 3.23  3.63, Hgb = 9.310.3, Hct = 30.133.7
4. Patient uses walker when ambulating and had no alteration in gait. No unsteadiness
5. Patient has both light and sharp touch intact
6. BP = 115/57, HR = 86, RR = 24, SpO2 = 92, and MAP = 72
7. Patient shows no changes in mental status during shift
8. Patient understands the importance of range of motions to promote circulation
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #7:

 Constipation r/t post-surgery, abnormal environment, and use of pain medications

General Goal:

 Patient will not have constipation.

Predicted Behavioral Outcome Objective(s):

 The patient will have at least 1 bowel movement on the day of care.

Nursing Interventions:

1. Encourage fluids of at least 750 ml during out time on the floor (7am – 1130 am) and at least 2000 – 3000 ml on
a daily basis
2. Administer stool softeners per orders (Colace) and if need PRN medications for bowels
3. Evaluate patient normal bowel pattern and assess for abnormalities during hospitals stay and post-surgery
4. Encourage ambulation to help with bowel regulation post-surgery
5. Education on fiber in diet (20g/day), food such as barley, oatmeal, beans, nuts, fruits. Eating regular meals 3
times a day with snacks if necessary
6. Assess bowel sounds for hypoactivity
7. Allow for privacy during defecation
8. Establish bowel routine in hospital

Patient Responses:

1. Patient drank 1000 ml during shift

2. Patient took medication with no problems. Had BM during shift – soft, brown. No need for PRN medications
3. Patients states that he normally does not have problems with defecation but has had issues in the hospital
4. Patients wanting to ambulate in the hallway at the beginning of my shift with no problems
5. Patient show understanding of the importance of fiber in his diet and states that he usually eat 2-3 meals a day
6. Patient bowel sounds are normal active upon assessment
7. Patient did want privacy during defecation. Stated that it does help with his bowel routine in the hospital.
patient was instructed to use call light when he was done
8. Patient states that he does defecate in the morning normally at home. This was continued in the hospital
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Post coronary artery bypass graft (CABG) x 3 & post aortic valve replacement

Problem #8:

 Impaired skin integrity r/t open heart surgery and chest tube sites

General Goal:

 Patient will have intact skin.

Predicted Behavioral Outcome Objective(s):

 The patient’s incision with be clean, dry and intact on the day of care.

Nursing Interventions:

1. Education about incision site. Report if there is pain, redness, irritation, increases drainage from site
2. Keep site clean, dry, and intact.
3. Assess temperature and WBCs for possible infection
4. Assess nutritional status. Important for wound healing.
5. Assess albumin and total protein levels
6. Assess incision site to make sure edges are intact and not separated
7. Encourage mobility to promotes circulation
8. Encourage fluid intake of at least 2000 – 3000 ml a day.

Patient Responses:

1. Patient reports no pain at the incision site except with movement. Also, there is no redness, irritation or
drainage
2. Incision is clean, dry, and intact
3. Temperature = 97.6 and WBCs = 11.0  12.8
4. Patient has good fluid intake of 1000 ml during shift but only eat half of his breakfast
5. On admission, albumin = 3.5 and total protein = 6.6
6. Incision site edges are intact with no redness or separation
7. Patient stated he want to ambulate the hallway at the beginning of shift.
8. During shift patient drank 1000 ml of fluids. Patient was not on any IV fluids