You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old man who had coronary artery bypass graft surgery four days ago. The patient has a history of chronic obstructive pulmonary disease exacerbated by heavy smoking. His postoperative course has been difficult, and he has suffered a number of setbacks. Staff members, despite their diligent efforts, have not been able to wean him off the ventilator since the surgery. He has required frequent suctioning throughout the shift, and he is being evaluated for the development of ventilator-associated pneumonia.
Today, when returning from lunch, you observed that an experienced nurse was suctioning your patient. His secretions were thick, and you observed that the nurse was instilling saline into the patient’s endotracheal tube as she was suctioning him. The patient turned red and began coughing, and it was obvious he was in distress.
You asked the nurse why she was instilling saline into his endotracheal tube. She replied that this was being done to loosen the secretions. You told her this was no longer an acceptable practice. She stated that she many years of critical care experience and she didn’t care what anyone said, that the only way you could loosen the patient’s secretions would be to instill saline. She also said that would be the last time she would do something for one of your patients while you were at lunch.
Determine a plan of care for the patient using the nursing process.
Define each step of the nursing process and align each step to critical thinking and clinical decision-making processes.
Format your care plan as a concept map using visual presentation software, such as bubbl.us from the College of Education Technology Resource Library
Click Web Tools.
Click Collaboration & Productivity.
Format your alignment of the nursing process with the critical thinking process and clinical decision-making process in a document, table, or other visual representation approved by your instructor.
Click the Assignment Files tab to submit your assignment.
Assignment adapted from Leading and Managing in Nursing (Ch. 21), by Patricia S. Yoder-Wise, 2015, St Louis, MI: Elsevier. Copyright 2015 by Elsevier. Adapted with permission
You are a staff nurse working in an intensive care unit and assigned to care for a 75-year-old man who had coronary artery bypass graft surgery
As an AI text-based model, I can’t directly create a concept map using visual presentation software like bubbl.us. However, I can outline a plan of care for the patient using the nursing process and align each step with critical thinking and clinical decision-making processes.
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**Patient: 75-year-old male post-coronary artery bypass graft surgery with chronic obstructive pulmonary disease and ventilator-associated pneumonia concerns.**
**Nursing Process:**
**Assessment:**
– Gather patient data including vital signs, oxygen saturation, lung sounds, sputum characteristics, ventilator settings, and patient response to interventions.
– Assess patient’s respiratory status, cardiac status, neurological status, and overall physiological response.
– Identify patient’s risk factors and comorbidities (e.g., COPD, smoking history).
**Diagnosis:**
– Identify nursing diagnoses based on assessment data:
– Impaired gas exchange related to ventilator-associated pneumonia and thick secretions.
– Ineffective airway clearance related to retained secretions and ineffective cough reflex.
**Planning:**
– Develop goals and outcomes:
– Improve gas exchange and oxygenation.
– Facilitate effective airway clearance.
– Prevent complications such as ventilator-associated pneumonia.
**Implementation:**
– **Gas Exchange:**
– Monitor oxygenation and ventilation closely.
– Collaborate with the medical team to adjust ventilator settings as needed.
– Administer prescribed medications (e.g., antibiotics for pneumonia, bronchodilators for COPD).
– **Airway Clearance:**
– Perform proper suctioning techniques as needed, ensuring to limit suction time to prevent hypoxia.
– Encourage coughing and deep breathing exercises.
– Provide chest physiotherapy as ordered.
– **Communication:**
– Educate the patient and family about the importance of maintaining a clear airway and respiratory hygiene.
– Collaborate with the interdisciplinary team to ensure holistic care.
**Evaluation:**
– Assess patient’s response to interventions:
– Monitor vital signs, oxygen saturation, and respiratory status.
– Evaluate effectiveness of airway clearance techniques.
– Review laboratory results to monitor for improvement or worsening of pneumonia.
**Alignment with Critical Thinking and Clinical Decision-Making:**
– **Critical Thinking:**
– Assessment: Collecting thorough and accurate data about the patient’s condition.
– Diagnosis: Analyzing assessment data to identify nursing diagnoses.
– Planning: Formulating appropriate goals and interventions based on assessment findings and diagnosis.
– Implementation: Utilizing evidence-based interventions and adapting care plans as needed.
– Evaluation: Assessing the effectiveness of interventions and modifying care plans accordingly.
– **Clinical Decision-Making:**
– Utilizing clinical judgment and evidence-based practice to make decisions about patient care.
– Prioritizing interventions based on patient acuity and identified needs.
– Collaborating with the interdisciplinary team to optimize patient outcomes.
– Evaluating the outcomes of interventions to determine the need for adjustments or changes in the plan of care.
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You can use this outline to create a visual concept map using bubbl.us or a similar tool, highlighting the connections between each step of the nursing process, critical thinking, and clinical decision-making.
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