Case Scenario # 3

Adult ICU
INSTRUCTIONS: For this case study, you will develop a Nursing Care Plan using SNL, the Standardized
Nursing Languages of NANDA, NOC and NIC (NNN). You will be completing the blank nursing care plan
that accompanies this scenario.

• Patient is a 58-year-old man admitted to a medicine unit one week ago with a diagnosis of
atypical pneumonia. He was doing fine yesterday on O2 6L by NC.
Time Vital Signs/Data Intervention/Tx Response
7am-12noon Urine Output = 0 ml
Requires increasing FiO2
12noon Lasix 40 mg IVP at 12noon O = 800 ml
1500 PO2 – 85% (on 100% rebreather mask) Tx to CCMU
• minimally moving air
• using accessary muscles for breathing
Arrival in CCMU • Unresponsive, Etomidate for the intubation
1515 • Breathing at 45 breaths/min, • Intubated w/ #8 Shiley
• Cyanotic, • Vent Settings: 100% FiO2, AC 14,
• Cold, mottled skin, and VT 650.
• Pedal pulses heard only by Doppler,
• Generalized edema.
• Rhythm = ST with a rate of 120.
• BP = 96/58.
• Temp = 96.6 axillary
1525 SPO2 drops to 70%. He is immediately suctioned for thick
Post Intubation tan secretions, copious amounts.
1530 SPO2 increases to 90%. First ABG = 90-
Post-suctioning 65-45-7.42-26.
Resp. rate = 14. His suction requirements
become minimal
1535 • BP drops to 57/36. Immediately
• Given 2.5 liters of 0.9% saline IV
• Started on Dopamine at 20
mcg/kg/min.
1545 His BP responded to 120/75.
Next 2 hours Dopamine is titrated down to 10
1545-1745 mcg/kg/min
IV fluid is decreased to 150 cc/hr.
Bilateral soft wrist restraints were
applied
As he became more responsive, he began
reaching for his ETT
1745-1845 • BP increased
Next hour • Became alert & oriented x 3
• Understood explanations given to him.
1850 The restraints were removed.

Adult ICU Medicine 1

 Functional Health Patterns*

Ø The Functional Health Patterns that are relevant for this gentleman are:
Activity-Exercise
Cognitive-Perceptual
Health Perception-Health Management
Ø Activity-Exercise is the most affected functional health pattern for this gentleman.
* Nursing assessment data is organized in Functional Health Patterns. Functional Health Patterns can help direct
the choice of Nursing Diagnoses. The eleven functional health patterns are Health Perception-Health Management;
Cognitive-Perceptual; Nutritional-Metabolic; Elimination; Activity-Exercise; Sleep/Rest; Self-Perception/Self-
Concept; Role/Relationship; Sexuality/Reproductive; Coping/Stress/Tolerance; and Value/Belief.

Choosing the Nursing Diagnosis (es)

These nursing diagnoses are appropriate for this patient. In practice, you may select
additional nursing diagnoses.

Nursing Diagnosis: Impaired Gas Exchange

Defining Characteristics: dyspnea, decreased O2 saturation despite high
FIO2, unresponsiveness, and cyanosis
Related Factors: atypical pneumonia and possible pulmonary embolus.

Nursing Diagnosis: Decreased Cardiac Output

Defining Characteristics: low BP, cyanosis, rapid heart rate, and
unresponsiveness
Related Factors Etiology: hypovolemia (he had received Lasix. Decreased BP is
common with the initiation of positive pressure
ventilation causing decreased venous return to the
heart especially in the face of hypovolemia) or
Entomidate side effect (minimal risk).

Ø While both nursing diagnoses are appropriate, for purposes of this exercise
let’s use

Impaired Gas Exchange.

Ø On the nursing care plan form write in the nursing diagnosis, identifying the
defining characteristics and related factors.

Adult ICU Medicine 2

Choosing the Nursing Outcomes (NOCs)

• The next step is to select nursing outcomes that can best affect this nursing diagnosis.

• Listed below are two appropriate nursing outcomes for this gentleman.

Nursing Outcome(s)
Respiratory Status: Gas Exchange
Indicators: Ease of breathing
Dyspnea at rest not present
Cyanosis not present
Neurological Status IER
Restlessness not present
Fatigue not present
Pao2 WNL
Paco2 WNL
O2 saturation WNL

Respiratory Status: Ventilation

Indicators: Respiratory rate IER*
Respiratory rhythm IER
Ease of breathing
Dyspnea at rest not present
Tidal volume IER
Vital capacity IER
*IER = In expected range

Select one of the above listed nursing outcomes for this care plan exercise, go to the
nursing care plan and check the indicators that you think will best measure your
patient’s progress towards the outcome that you’ve chosen. You will need to rate you
patient’s current status for each indicator.

Now that you have chosen your outcome for this gentleman, you will select the
interventions that will best meet this outcome.

Adult ICU Medicine 3

Choosing the Nursing Interventions - NIC

• If you have chosen the NOC, Respiratory Status: Gas Exchange continue
below.

• If you have chosen the NOC, Respiratory Status: Ventilation go to that

section and select your interventions and activities.

NOC - Respiratory Status: Gas Exchange

The following two Nursing Interventions, Acid – Base Management and Energy
Management are appropriate for this gentleman. Review the activities listed
below each NIC and select 5 activities that apply. Write these five on the
nursing care plan in the activity column respectively for Acid-Base
Management and Energy Management.

NIC: Acid-Base Management3(pg.118)

• Maintain patent IV access • Maintain patent airway • Monitor ABG & electrolyte
levels
• Monitor hemodynamic status • Position to facilitate adequate • Monitor for symptoms of
ventilation respiratory failure
• Monitor for respiratory • Monitor determinants of • Provide oxygen therapy
pattern tissue oxygen delivery
• Provide mechanical ventilatory • Monitor determination of • Obtain ordered specimen for
support oxygen consumption lab analysis of acid-base
balance
• Monitor for worsening • Reduce oxygen consumption • Monitor neurological status
electrolyte imbalance
• Provide frequent oral hygiene • Promote orientation • Monitor for loss of acid( e.g.
vomiting)
• Monitor for loss of • Administer prescribed alkaline • Instruct pt &/or family on
bicarbonate(e.g. fistula medications based on ABG actions instituted to treat the
drainage & diarrhea) results acid-base imbalance

Adult ICU Medicine 4

Again, review the activities listed below the NIC and select 5. Write these
five on the nursing care plan in the activity column for Energy Management.

NOC: Respiratory Status: Gas Exchange

NIC: Energy Management3 (pg.302) Activities
• Determine pt’s physical • Limit environmental stimuli to • Encourage verbalization of
limitations facilitate relaxation feelings about limitation
• Determine causes of • Monitor nutritional intake to • Determine pt’s/significant other’s
fatigue(e.g. treatments, pain & ensure adequate energy perception of causes of fatigue
medications) resources
• Monitor/record pt’s sleep • Monitor pt for evidence of • Monitor cardiorespiratory
pattern & number of sleep excess physical & emotional response to activity
hours fatigue
• Consult with dietitian about • Arrange physical activities to • Reduce physical discomforts that
ways to increase intake of reduce competition for oxygen could interfere with cognitive
high-energy foods supply to vital body functions function & self-
(e.g. avoid activity immediately monitoring/regulation of activity
after meals)
• Set limits with hyperactivity • Determine what & how much • Monitor location & nature of
when it interferes with others activity is required to build discomfort or pain during
or with the pt endurance movement/activity
• Promote bedrest/activity • Encourage alternate rest & • Limit number of & interruptions
limitation activity periods by visitors
• Use passive &/or active range • Provide calming diversional • Encourage an afternoon nap
of motion exercises to relieve activities to promote
muscle tension relaxa6tion
• Assist pt to schedule rest • Avoid care activities during • Plan activities for periods when
periods scheduled rest periods the pat has the most energy
• Assist patient to sit on side of • Assist with regular physical • Monitor administration & effect
bed, if unable to transfer or activities of stimulant & depressants
walk
• Encourage physical activity • Monitor pt’s oxygen response • Assist pt to understand energy
to self-care or nursing conservation principles
activities
• Instruct pt/SO to recognize • Instruct pt/so to notify • Teach pt & significant other
signs & symptoms of fatigue health care provider if signs 7 techniques of self-care that will
that require reduction in symptoms of fatigue persist minimize oxygen consumption
activity
• Assist pt to identify task that • Assist pt to self-monitor by • Assist pt to limit daytime sleep to
family & friends can perform developing & using a written providing activity that promotes
in the home to prevent/relieve record of calorie intake & wakefulness
fatigue energy expenditure
• Encourage pt to choose • Assist pt to identify • Evaluate programmed increases in
activities that gradually build preferences for activity levels of activities
endurance
Assist pt/so to establish realistic activity goals

Adult ICU Medicine 5

NOC: Respiratory Status: Ventilation
• Select 5 nursing activities that are appropriate for this patient and write them on
the care plan in the activity column for Airway Management.

NIC: Airway Management: Activities3(pg.132)

• Open the airway, using chin lift or jaw • Position pt to maximize • Identify pt requiring
thrust technique ventilation potential actual/potential airway
insertion
• Insert oral or nasopharyngeal airway • Perform chest physical • Administer bronchodilators
therapy
• Encourage slow, deep breathing; • Instruct how to cough • Assist with incentive
turning; & coughing effectively spirometer
• Auscultate breath sounds, noting areas • Perform endotracheal or • Remove secretions by
of decreased or absent ventilation & nasotracheal suctioning encouraging coughing or
presence of adventitious sounds suctioning
• Teach pt how to use prescribed inhalers • Administer humidified air • Regulate fluid intake to
or oxygen optimize fluid balance
• Administer ultrasonic nebulizer • Monitor respiratory & • Administer aerosol
treatments oxygenation status treatments
• Position to alleviate dyspnea

NIC: Mechanical Ventilation: Activities3 (pg. 431)

• Monitor for respiratory muscle • Monitor for impending • Instruct pt & family about rationale
fatigue respiratory failure & expected sensations associated
with use of mechanical ventilators
• Monitor for decrease in exhale • Provide oral care • Monitor effectiveness of mechanical
volume & increase in ventilator on pt’s physiological &
inspiratory pressure psychological status
• Initiate calming techniques • Monitor ventilator pressure • Position to facilitate
readings & breath sounds ventilation/perfusion matching
• Monitor pt’s progress on • Monitor for adverse • Stop NG feedings during suctioning
current ventilator settings & effects of mechanical & 30-60 minutes before chest
make appropriate changes ventilation: infections, etc. physiotherapy
• Collaborate with physician to • Perform chest physical • Perform suctioning, based on
use CPAP or PEEP to minimize therapy adventitious sounds &/or ventilatory
alveolar hypoventilation pressures
• Monitor degree of shunt, vital • Monitor effects of • Administer muscle-paralyzing agents,
capacity, MVV, Vd/Vt, ventilator changes on sedatives, & narcotic analgesics
inspiratory force, & FEV1 for oxygenation: ABG, SaO2,
readiness to wean from SvO2, end-tidal CO2, Qsp/Qt
mechanical ventilation, based & A-aDO2 levels & pt’s
on agency protocol subjective response
• Promote adequate fluid & nutritional intake

Adult ICU Medicine 6

 Congratulations!

You have successfully completed your first nursing care plan using
the standardized nursing language vocabularies of NANDA, NOC and
NIC.

1. If you wish to received CE for this educational activity, please

complete the evaluation form and return along with $10 to:
Carol Williams, MS, RN, C
Educational Services for Nursing
University of Michigan Health System
300 North Ingalls, 6B12
Ann Arbor, Michigan 48109-0436
2. If you are working with a coordinator please give your quiz, evaluation
and completed nursing care plan to your coordinator.

Adult ICU Medicine 7

 Adult ICU
NURSING DIAGNOSIS Patient Name
Defining Characteristics (Signs & Symptoms)
❏ ❏ ❏
❏ ❏ ❏
❏ ❏ ❏

Related Factors (Etiology)

❏ ❏
❏ ❏
❏ ❏

NOCs (Outcomes)
Measurement Scale Score:
1 = Severe
2 = Substantial
3 = Moderate
Respiratory
4 = Slight
Status 5 = None
Ventilation ❏ respiratory rate IER*
❏ respiratory rhythm IER
❏ ease of breathing
❏ dyspnea at rest not present
❏ tidal volume IER
❏ vital capacity IER
DATE/TIME
INITIALS

Measurement Scale Score:

1 = Severe
2 = Substantial
3 = Moderate
Respiratory 4 = Slight
Status: 5 = None
❑ ease of breathing
Gas ❑ dyspnea at rest not present
Exchange ❏ cyanosis not present
❑ neurological status IER
❏ restlessness not present
❏ fatigue not present
❏ Pao2 WNL**
❏ Paco2 WNL
❏ O2 saturation WNL
DATE/TIME
INITIALS

*IER = in expected range **WNL = within normal limits

Adult ICU Medicine 8

NIC (interventions) ACTIVITIES: MODIFICATIONS:
❑

❑
Energy
Management ❑

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❑:

❏
Mechanical ❏
Ventilation ❑

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏

Acid-Base ❏
Management ❏

DATE/TIME
ACTIVITIES: MODIFICATIONS:
❏

❏
Airway
❏
Management
❏

DATE/TIME
OTHER INTERVENTIONS: SIGNATURE BOXES:
• •
• •

Adult ICU Medicine 9