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
• Monitor hemodynamic status
• Monitor for respiratory
pattern
• Provide mechanical ventilatory
support
• Monitor for worsening
electrolyte imbalance
• Provide frequent oral hygiene
• Monitor for loss of
bicarbonate(e.g. fistula
drainage & diarrhea)
• Maintain patent airway
• Position to facilitate adequate
ventilation
• Monitor determinants of
tissue oxygen delivery
• Monitor determination of
oxygen consumption
• Reduce oxygen consumption
• Promote orientation
• Administer prescribed alkaline
medications based on ABG
results
• Monitor ABG & electrolyte
levels
• Monitor for symptoms of
respiratory failure
• Provide oxygen therapy
• Obtain ordered specimen for
lab analysis of acid-base
balance
• Monitor neurological status
• Monitor for loss of acid( e.g.
vomiting)
• Instruct pt &/or family on
actions instituted to treat the
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
limitations
• Determine causes of
fatigue(e.g. treatments, pain &
medications)
• Monitor/record pt’s sleep
pattern & number of sleep
hours
• Consult with dietitian about
ways to increase intake of
high-energy foods
• Set limits with hyperactivity
when it interferes with others
or with the pt
• Promote bedrest/activity
limitation
• Use passive &/or active range
of motion exercises to relieve
muscle tension
• Assist pt to schedule rest
periods
• Assist patient to sit on side of
bed, if unable to transfer or
walk
• Encourage physical activity
• Instruct pt/SO to recognize
signs & symptoms of fatigue
that require reduction in
activity
• Assist pt to identify task that • Assist pt to self-monitor by
family & friends can perform
in the home to prevent/relieve
fatigue
• Encourage pt to choose
activities that gradually build
endurance
Assist pt/so to establish realistic activity goals
• Limit environmental stimuli to
facilitate relaxation
• Monitor nutritional intake to
ensure adequate energy
resources
• Monitor pt for evidence of
excess physical & emotional
fatigue
• Arrange physical activities to
reduce competition for oxygen
supply to vital body functions
(e.g. avoid activity immediately
after meals)
• Determine what & how much
activity is required to build
endurance
• Encourage alternate rest &
activity periods
• Provide calming diversional
activities to promote
relaxa6tion
• Avoid care activities during
scheduled rest periods
• Assist with regular physical
activities
• Monitor pt’s oxygen response
to self-care or nursing
activities
• Instruct pt/so to notify
health care provider if signs 7
symptoms of fatigue persist
developing & using a written
record of calorie intake &
energy expenditure
• Assist pt to identify
preferences for activity
• Encourage verbalization of
feelings about limitation
• Determine pt’s/significant other’s
perception of causes of fatigue
• Monitor cardiorespiratory
response to activity
• Reduce physical discomforts that
could interfere with cognitive
function & self-
monitoring/regulation of activity
• Monitor location & nature of
discomfort or pain during
movement/activity
• Limit number of & interruptions
by visitors
• Encourage an afternoon nap
• Plan activities for periods when
the pat has the most energy
• Monitor administration & effect
of stimulant & depressants
• Assist pt to understand energy
conservation principles
• Teach pt & significant other
techniques of self-care that will
minimize oxygen consumption
• Assist pt to limit daytime sleep to
providing activity that promotes
wakefulness
• Evaluate programmed increases in
levels of activities

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

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