1

Step 1. Write the key problems the patient has based on the data collected. The key
problems are also known as the concepts. Start by centering the reason for seeking health
care (often a medical diagnosis). Next, list the major problems you have identified based
on the assessment data collected on the patient.

Key Problem Key Problem Key Problem

Risk for compromised Ineffective Tissue Perfusion
Risk for hemodynamic family coping r/t
instability Supporting Data:
unrealistic expectations. Hypovolemia
Supporting data: (tachycardia, blood loss)
Secondary to Supporting data: Low hemoglobin
respiratory failure Poor Abnormal ABGs
Changes in LOC understanding of (respiratory acidosis =
Metabolic patient current hypoventilation)
acidosis
condition
Mottling of the
skin
Deficient
Oliguria Key Problem
Risk for Decreased
Key Problem: Reason for Needing Health Care
Cardiac Output
imbalanced nutrition -
less than body Respiratory Failure Supporting Data:
requirements
Epidural hematoma Elevated
troponin levels
Supporting data: Cardiac Arrest Tachycardia
Hypoactive
Edema
bowel sounds
Respiratory
No
acidosis
PO/TPN/TF
intake

Key Problem/ND Risk for increased ICP d/t Key Problem

Impaired Spontaneous traumatic head injury Increased risk for ineffective gas
exchange
Ventilation
Supporting Data:
Supporting Data: ETT Intubation
Supporting Data: Epidural SPO2<93
Respiratory Acidosis
AC/VC Hematoma Atelectasis
Diminished Breath Sounds
ventilation Maintenance Hypoventilation
Lifebanc fluids of Abnormal ABG values

RR=15 125ml/hr/bolus PRN

Decreased LOC to treat Hypotension
Increased
PT/INR
 2

Step 2. Support problems with clinical patient data, including abnormal physical
assessment findings, treatments, medications, and IV’s, abnormal diagnostic and lab
tests, medical history, emotional state and pain. Also, identify key assessments that are
related to the reason for health care (chief medical diagnosis/surgical procedure) and put
these in the central box. If you do not know what box to put data in, then put it off to the
side of the map.

#1 Key Problem/ND #2 Key Problems/ND #3 Key Problem/ND

Risk for hemodynamic instability Risk for compromised Ineffective Tissue Perfusion
family coping r/t
Supporting data:
unrealistic expectations. Supporting Data:
Secondary to Hypovolemia
respiratory failure (tachycardia, blood loss)
Changes in LOC Supporting data:
Low hemoglobin
Metabolic acidosis Poor Abnormal ABGs
Mottling of the skin understanding of (respiratory acidosis =
Oliguria #9 See separate
patient current hypoventilation)
Tachycardia page
condition Hypoactive bowel
Hypotension
Lack of any brain
Deficient sounds
knowledge of Elevated BUN
activity
Organ Failure
#5 Key Problem: imbalanced
#4 Key Problem/ND
nutrition - less than body
Risk for Decreased Cardiac
requirements
Output
Supporting data: Reason For Needing Health Care
Supporting Data:
Hypoactive bowel (Medical Dx/ Surgery)
Elevated
sounds
troponin levels
No PO/TPN/TF
Respiratory Failure Tachycardia
intake
Edema
Insufficient muscle Epidural hematoma Respiratory
tone/strength
Cardiac Arrest acidosis
dec regular stool
Intubation
output
Low SpO2
Hx drug abuse
Elevated lactate
levels

#6 P
Key Problem/ND #7 Risk for increased ICP d/t #8 Key Problem/ND
Impaired Spontaneous traumatic head injury
Ventilation Increased risk for ineffective gas
Supporting Data: exchange
Supporting Data: Epidural Hematoma
Supporting Data:
AC/VC ventilation Maintenance fluids ETT Intubation
Pt. on Lifebanc of 125ml/hr/bolus PRN SPO2<93
RR = 15 to treat Hypotension Respiratory Acidosis
Atelectasis
Decreased LOC Increased PT/INR Diminished Breath Sounds
FiO2 = 40% due to liver trauma and Hypoventilation
vT = 616 mL anticoagulation need to Abnormal ABG values
PEEP = 8 cmH2O preserve organs
Uncompensated
metabolic acidosis (day
of care)
H
 3

Problem #1: Risk for Hemodynamic Instability

General Goal: Patient remains hemodynamically stable and condition does not
worsen.

Predicted behavioral Outcome Objective(s): The patient will… have

physiologic and mechanical assistance to ensure a blood pressure of (90/60) and
cardiac output (BPM 60-100) remains within normal limits on the day of care.

Nursing Strategies/Interventions: Patient Responses:

1. Monitor vital signs 1. Tachycardic, vitals WDL

2. Assess LOC/ Q1H neuro checks 2. LOC-3, unresponsive
3. Maintain mechanical ventilation settings 3. A/C, FiO2 40%, PEEP 8
4. Monitor for alterations in BP 4. Patient
5. Administer meds as prescribed 5. Meds administered
6. Check pulses for adequate perfusion 6. 3+ pulses, edema noted
7. Evaluate ventricular function & RR/depth 7. A/C on ventilator, rate 15
8. Assess for decreased CO (tachy, oliguria) 8. Tachycardic, BP
fluctuates

Evaluation: Summarize patient progress toward outcome objective:

Patient is progressing- remains hemodynamically stable for purposes of lifebank/

organ donation.
 4

Problem #2: Risk for compromised family coping r/t unrealistic

expectations

General Goal: Family will express more realistic understanding and acceptance
of current patient standing

Predicted behavioral Outcome Objective(s): The family will… express more

realistic expectations and understanding of the patient's current medical status
on the day of care.

Nursing Strategies/Interventions:

(see next page)

Nursing Strategies/Interventions:
 5

1. Use empathetic and effectively and the family was

therapeutic communication more willing to listen as this
built trust and a supportive
relationship.
2. Provide opportunity for family 2. Family, nurse and doctors
to discuss concerns, fears, were able to speak with family
expectations multiple times to update and
explain patient status which
reduced anxiety.
3. Encourage spiritual resources 3. Mentioned to family members
that spiritual resources are
helpful and can be provided
for their convenience.
4. Encourage counselor services 4. Nurse recommended
counseling for the patient's
young nephew who was
struggling to comprehend the
patient's situation.
5. Identify specific stressors 5. Family stressors included
being out of state, being
unable to be with patient,
grief, deficient knowledge,
feeling loss of control.
6. Assist in setting realistic goals
6. Family was involved in
decision making which helped
them to make realistic
7. Provide information the family
decisions.
wants and needs but not more
7. Doing so helped the family
than they can handle
understand one piece of
8. Be supportive of coping information at a time to avoid
behaviors overwhelm and stress
8. A supportive environment
1. Family response: Nurse was enhances coping.
able to communicate

Evaluation: Summarize patient progress toward outcome objective:

Family continues to progress.

Problem #3: Ineffective Tissue Perfusion

General Goal: Patient shows no further worsening of deficits

 6

Predicted behavioral Outcome Objective(s): The patient will… maintain tissue

perfusion to vital organs, as evidenced by warm skin, present and strong pulses
and balanced intake and output on the day of care.

Nursing Strategies/Interventions: Patient Responses:

1. Monitor Vital Signs 1. Tachycardic

2. Assess Peripheral Pulses 2. 3+ pulses =
normal
3. Assess Bowel Sounds 3. Hypoactive
4. Monitor Urine Output 4. WDL
5. Frequent Neuro Exams/Assess LOC 5. Unresponsive-
LOC = 3
GCS = 3
6. Administer Medications as Ordered 6. Met
7. Maintain Oxygen Therapy as Ordered 7. On Ventilator
(A/C)
8. Elevate HOB 30-45° 8. HOB Kept at 30-
45°

Evaluation: Summarize patient progress toward outcome objective:

Progressing → Lifebanc patient, they are being monitored for organ

donation.
 7

Problem #4: Risk for decreased cardiac output

General Goal: Patient’s cardiac output will be within normal limits

Predicted behavioral Outcome Objective(s): The patient’s vital signs will be

within normal range on the day of care.

Nursing Strategies/Interventions: Patient

Responses:

1. Assess heart rate and blood pressure 1. Tachycardic,

hypertensive
2. Check peripheral pulses 2. Pulses 3+
3. Auscultate heart sounds 3. S1,S2 heard
4. Monitor for fluid retention 4. No abnormal weight
gain
5. Assess respiratory rate/effort, breath sounds 5. On ventilator (A/C), rate
of 15, diminished
6. Perform neuro checks/ assess LOC 6. Unresponsive LOC 3,
GCS 3
7. Assess CVP 7. CVP 11 (WDL)
8. Monitor skin color, temp, check for edema 8. Peripheral edema
present, skin warm, skin

Evaluation: Summarize patient progress toward outcome objective:

Patient is progressing-being monitored for effective tissue perfusion

for Lifebanc.
 8

Problem #5: Imbalanced Nutrition - less than body requirements

General Goal: patient will weigh within normal range for height (6’) and age (33y)

Predicted behavioral Outcome Objective(s): The patient will not weigh in with
> 3lb difference from previous day’s weight on the day of care.

Nursing Strategies/Interventions:

daily weights
monitor electrolyte levels
monitor fluid intake & output
document stool output (occurrences, character, consistency)
administer supplements as ordered (multivitamins, electrolyte supplements)
monitor blood sugar
monitor albumin levels (may fluctuate with malnutrition)
assess bowel sounds and abdominal character per shift protocol

Patient Responses:

maintaining weight at 186lb

inc sodium (154) rt TBI, inc calcium (8.6) rt blood loss, inc chloride (121) rt TBI
day of care IV fluid intake 750mL, urine output 315
no stool output during day of care
hyperglycemic 176 (rt trauma, stress)
albumin within normal range
hypoactive bowel sounds, no abdominal distention, soft abd on palpation

Evaluation: Summarize patient progress toward outcome objective:

patient maintaining documented admission weight of 186lbs. will most likely not
gain much weight while under care dt no nutritional supplementation (TPN/TF)
being ordered. will not progress back to normal weight for 33y/o 6 foot male since
pt on LifeBanc.
 9

Problem #6: Impaired Spontaneous Ventilation

General Goal: Patient will demonstrate an absence of complications from the

mechanical ventilation.

Predicted behavioral Outcome Objective(s): The patient will remain free from
further complications related to the use of mechanical ventilation as evidenced by
oxygen saturation >93% and respiratory rate between 12-20 on the day of care.

Nursing Strategies/Interventions:

1. Assess the patient's respiratory rate

2. Monitor oxygen saturation
3. Auscultate the patient’s lung fields
4. Monitor the patient’s ABG’s
5. Assess the patient’s skin color and capillary refill
6. Maintain High-Fowler's position as tolerated
7. Maintain aseptic technique when suctioning the airway
8. Maintain mechanical ventilation at the prescribed settings

Patient Responses:

1. RR = 15 on A/C setting
2. O2 sat @ 95
3. Lung sounds diminished bilaterally
4. Uncompensated metabolic acidosis (HCO3 = 19.5 and pH = 7.34)
5. Skin is pink/appropriate to ethnicity and cap refill <3 seconds
6. Pt. was able to tolerate bed @ 45°
7. Pt. remained free of infection localized in the airway
8. Pt. maintained adequate ventilation as evidence by O2 saturation and
respiratory rate within normal range

Evaluation: Summarize patient progress toward outcome objective:

Outcome objective → met. However, the patient is on Life Banc and will not
progress to be able to take breaths of his own. Therefore, they will not be able to
progress to spontaneous ventilation.
 10

Problem #7:

General Goal: Decrease ICP

Predicted behavioral Outcome Objective(s): The patient will maintain an ICP

less than 15 on the day of care.

Nursing Strategies/Interventions:

1. Maintain HOB at 45 degrees or more to prevent fluid collection around

brain
2. Continue to assess need for fluid volume management
3. Combine/group care
4. Assess level of edema to provide the correct amount of fluid volume
management

Patient Responses:

1. HOB was kept at 45 degrees or higher

2. Pt continued to need constant fluids
3. Pt was turned and disturbed as little as possible to maintain a normal ICP
4. Edema was still present during shift

Evaluation: Summarize patient progress toward outcome objective:

Monitoring ICP was difficult on this patient due to the lack of typical indicators
that would show that the ICP is elevated. Pupils were non reactive and cognition
was not present so all the usual steps were taken to maintain a normal ICP
however it is unable to be assessed on this particular patient.
 11

Problem #8: Increased risk for ineffective gas exchange

General Goal: SPO2> 93 with ABGs within neutral range

Predicted behavioral Outcome Objective(s): The patient will…maintain SPO2

greater than 93% via intubation with ABGs trending more neutral on the day of
care.

Nursing Strategies/Interventions: Patient

Responses:

1.Obtain chest Xray and assess lung fields 1. Atelectasis still

present

2. Keep airway patent with hourly checks 2. AC mechanical

ventilation

3. Draw Q4 ABGs for evaluation 3. Respiratory Acidosis

4. Provide ETT care 4. Suctioned with thick mucus

present

5. Perform oral care 5. Met with no signs of

infection

6. Maintain HOB elevated 30-45 6. Goal met; diminished breath

sounds

7. Change patient positioning Q2 7. Goal met with airway

maintained

8. Administer prophylactic antibiotics 8. Airway maintained infection

free

Evaluation: Summarize patient progress toward outcome objective:

Treatment is ongoing to decrease ventilator settings for weaning and to

continually improve ABG values.
 12

Problem #9: Ineffective Cerebral Tissue Perfusion/Risk for Brainstem

Herniation (Sophie)

General Goal: The patient will display adequate perfusion as evidenced by

stable vital signs and hemodynamics.

Predicted behavioral Outcome Objective(s): The patient will maintain an

expected level of consciousness, motor response, sensory function, and
cognition on the day of care. (Expected or predicted, not as in the form of a goal)

Nursing Strategies/Interventions: Patient Responses

1. Monitoring changes in neurologic status and GCS 1. GCS 3

2. Monitor for signs of Cushing’s Triad 2. (-)

3. Evaluate Diagnostics (CT) 3. (+) Epidural

Hematoma

4. Combine/group care 4. UTA

5. Monitor pupillary responses 5. Fixed, non reactive

6. Monitor the patient’s bilateral motor responses 6. No posturing

present

7. Maintain head or neck in midline or neutral position 7. Maintained

8. Prep for pre and post op interventions 8. Exploratory crani

 13

Evaluation: Summarize patient progress toward outcome objective:

This evaluation is up to interpretation, nothing was gained from this diagnosis

other than the need for brain death testing to truly gauge the matter of the
situation. The patient has severe brain damage with great risk for irreversible
damage to the brainstem which is fatal. If deemed brain dead (which the pt was)
then obviously this nursing diagnosis would not be met and none of these would
be met. Death time would be pronounced (9/28 @1548) and Lifebanc would then
be consulted and take over care and continue searching for potential recipients
for the recruited organs (which is what happened). However, the expected
baseline for this patient with such complex of injury is pretty understood with an
admission GCS of 3.