Care Plan

Student: Ahsan Arca Date: 2/4/2020

Course: NSG-430CC Instructor: Sheila Arnberger

Clincial Site: Banner Del Webb: ICU Client Identifier: S.W. Age: 79 y/o

Reason for Admission: S.W. came to the E.D. on 1/20/20 with stomach pain and N/V. She was then transferred to the ICU on 1/24/20 from
the med-surg floor after sustaining a PEA. After successful rescucitation, she sustained complications that put her in acute respiratory
distress syndrome (ARDS).

Medical Diagnoses: (Include Pathophysiology and Risk Factors [r.f.]): Clinical Manifestations (C.M.):
ARDS: a condition in which the lungs cannot get adequate amount of S.W. experienced shortness of breath, decrease in blood pressure,
oxygen due to an accumulation of fluid in the alveoli. This occurs when and rapid breathing (“Mayo Clinic”, 2019).
the protective membrane around the alveoli is compromised due to Other S.W. include: confusion and fatigue (“Mayo Clinic”, 2019).
physical damage or illness. Risk factors include critically ill patients,
sepsis, infections, pneumonia, and chronic alcoholism (“Mayo Clinic”,
2019).

Assessment Data

Subjective Data: S.W. was intubated, however, her chart specified that she came in complaining of extreme abdominal pain, rated at 9/10
on the numeric pain scale, along with N/V that began two days prior to arrival to the ED.

VS: Labs: Diagnostics:

2/4/20 at 0800 Taken on 2/4/20 at 0340: Taken on 2/3/20 at 1650
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
T : 36.4 C WBC 25.0K/mm^3 (normal 4,000-11,000) CT Abd/pelvis:

BP: 108/39 bpm  WBC is high when sepsis is present; the  b/l pleural effusions
client is currently recovering from sepsis  edema of duodenal bulb and postbulbar
HR: 94 bpm (“Sepsis Alliance”, 2020). duodenum
RR: 18 breaths/min  loculated fluid collections within abdomen
RBC 2.64 m/mm^3 (normal 3,800,000-
O2 Sat: 97% on mechanical 5,000,000/mcL)
ventilator (FiO2 at 40% and
PEEP of 5.0).  Low due to blood loss that occurred
when client sustained perforation in the
Pain: no s/s of pain abdomen (“AACC”, 2019).
2/4/20 at 1030 Hgb 7.9 g/dL (normal: 11.7-17.3 g/dL)
T : 36.8 C
 Low due to the decrease in RBCs from
BP: 115/55 bpm blood loss (“AACC”, 2019).

HR: 85 bpm Hct: 24.6% (normal 35-50%)

RR: 18 breaths/min
O2 Sat: 97% on mechanical
ventilator (FiO2 at 40% and
PEEP of 5.0).
Pain: no s/s of pain
 Decreased due to the loss of blood that
occurred from ulcer perforation in the
abdomen (“AACC”, 2019).
Platelet: 500K/mm^3 (normal 150,000-400,000)
 Platelet is high due to an increase in
blood clot formation, as her body
recovers from perforation (“Sepsis
Alliance”, 2020).
BUN: 42 mg/dL (normal 6-20)

 Increased due to the decrease in blood

flow to the kidneys, which occurred as a
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 result of PEA (“AACC”, 2019).
Cr: 2.82 mg/dL (normal 0.2-1.0)

 Increased as a result of kidney damage

caused by sustained infection and/or
decrease in blood flow to her kidneys
(“AACC”, 2019).
Comparison: taken on 2/3/20 at 0338
WBC 21.6 K/mm^3
RBC 2.64 m/mm^3
Hgb 8.0 g/dL
Hct: 24%
Platelet: 435K/mm^3
BUN: 44 mg/dL
Cr: 2.81 mg/dL
Normal values reference (Lewis, Bucher,
Heitkemper, Harding, Kwong, & Roberts, 2017).

Assessment: Orders:
PMH: neuropathy, osteopenia, overweight, stenosis of artery on left Enteral tube: Nepro 35mL/hr
lower extremity.
Oral care every 2-4 hrs
Neuro: Patient intubated, opens eyes to voice, and follows simple
Cardiac monitoring
commands. PERRLA noted, and pupil size 3mm b/l (bilaterally).
Full code
Respiratory: cough absent. Respiration unlabored with symmetrical
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expansion at 18 breaths/min. She was laying in bed, with HOB at 30.
Breath sounds were clear to auscultation in upper lobes b/l and
diminished with fine crackles in lower lobes b/l. Mechanical ventilator
setting: A/C mode, FiO2 at 40%, PEEP 5.0, tidal volume 450mL. ET tube
size of 8.0cm. Oral care: complete assist.
Cardiovascular: nail beds color are pink and appropriate to ethnicity.
Capillary refill <3sec b/l in UE and LE. Heart rhythm was regular; s1 and
s2 heard, with no murmurs or bruit. Cardiac rhythm was NSR. Dorsalis
pedis pulses and radial pulses approximately 2+ b/l. 2+ pitting edema
on LE b/l.
GI: rounded, firm, and nontender abdomen. Normal bowel sounds in
all 4 quadrants. Last BM was on 2/4/20 at approximately 0815. Rectal
tube in place. Diet: Nepro tube feeding, running at 35mL/hr
GU: indwelling catheter in place. Intake of 376mL and output of 0mL at
1000.
Musculoskeletal: Weakness present in all extremities b/l. ROM equal in
UE and LE b/l. Compression stockings/devices were not implemented.
Integumentary: warm, dry, and intact skin. Color appropriate to
ethnicity. Bruising present on LE, b/l. Skin turgor appropriate. Mucous
membrane was pink and moist.
Lines: central triple lumen line on L IJ; dressing was clean, dry, and
intact. NG tube in right nare (16F); length could not be determined.
Rectal tube in place.

Medications
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ALLERGIES: Cyclobenzapine.

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
81mg, 1 PO Once daily “Prophylaxis of transient GI bleed, tinnitus, and Assess patient’s
Aspirin (Aspir-Low) tab ischemic attacks and MI” hemolysis (Vallerand & allergies. Monitor
(Vallerand & Sanoski, Sanoski, 2017). hepatic function
2017, p.1). prior to
Therapeutic effect: administration.
“decreases platelet Take with food to
aggregation” (Vallerand & reduce gastric
Sanoski, 2017, p.1110). upset. Common s.e.
include dyspepsia,
stomach upset, and
nausea (Vallerand
& Sanoski, 2017).
400mg, 2 PO Once daily Used to treat herpes Seizures, renal failure, and Monitior client’s
Acyclovir (Sitavig) caps infections and shingles. Stevens-Johnson neurological
Therapeutic effect: syndrome (Vallerand & function. Monitor
“interferes with viral DNA Sanoski, 2017). BUN and Cr for
synthesis” (Vallerand & renal function.
Sanoski, 2017, p.108). Assess patient’s
lesions. Common
s.e. include:
dizziness,
headache, and
diarrhea (Vallerand
& Sanoski, 2017).

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 12.5mg PO BID Used to decrease the rate
Metoprolol of mortality in patients
(Metoprolol Tartrate) with MI.
Therapeutic effect:
“blocks stimulation of
beta1 receptors” to
decrease BP (Vallerand &
Sanoski, 2017, p.839).
Clopidogrel (Plavix) 75mg, 1 PO Once daily Used to reduce
tab “atherosclerotic events”.
Therapeutic effect:
“inhibits platelet
aggregation by
irreversibly inhibiting the
binding of ATP to platelet
receptors” (Vallerand &
Sanoski, 2017, p.330).
Pantoprazole 40mg IV push BID Used to prevent GERD
(Protonix) (Vallerand & Sanoski,
2017).
Therapeutic effect: “binds
to an enzyme in the
presence of acidic gastric
pH, preventing final
transport of hydrogen
ions” (Vallerand &
Pulmonary edema, HF, and Assess BP and ECG
memory loss (Vallerand & to note changes.
Sanoski, 2017). Monitor I&Os and
s/s of HF. Do not to
abruptly stop
medication, as
complications may
occur. Common s.e.
include:
hypotension,
weakness, and
fatigue (Vallerand
& Sanoski, 2017).
GI bleed, toxic epidermal Discontinue 5-7
necrolysis, and days prior to
neutropenia (Vallerand & surgery. Assess for
Sanoski, 2017). s/s of stroke or MI.
monitior BT during
therapy. Common
s.e.: dizziness,
pruritus, and fever
(Vallerand &
Sanoski, 2017).
CDAD, abdominal pain, Assess client for
and bone fracture abdomnial pain or
(Vallerand & Sanoski, bloody stools.
2017). Monitor client’s
bowel
sounds/function.
Common s.e.
include diarrhea,
hyperglycemia, and
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 Sanoski, 2017, p.972). headache
(Vallerand &
Sanoski, 2017).
Heparin (Hepalean) 5,000 SQ TID Prophylactic treatment Bleeding, HIT, and anemia Assess pt. for signs
units for venous (Vallerand & Sanoski, of bleeding.
thromboembolism. 2017). Monitor platelet
Therapeutic effect: count throughout
potentiates antithrombin therapy. Monitor
effect (Vallerand & for hypersensitivity
Sanoski, 2017). reactions. Common
s.e. include
injection-site pain,
fever, and alopecia
(Vallerand &
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time- Nursing or interprofessional Provide reason why Was goal met? Revise
specific, reasonable, and interventions. intervention is the plan of care
attainable. indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Ineffective breathing pattern r/t compromised cardiac function AEB dyspnea (Phelps, Ralph, & Taylor, 2017). This was chosen as the priority
diagnosis, as the need for air is considered as one of the basic needs of life, according to Maslow’s Hierarchy of needs (Friberg & Creasia,
2016).
The patient will have 1. “to detect early sign of The goal was met.
maximum chest 1. “Assess and record respiratory 1. The client’s
The patient will not expansion at 16-20 respiratory rate and compromise” (Phelps, respiratory
present with dyspnea. breaths/min by the end of depth at least every [2] Ralph, & Taylor, 2017, efforts were
the shift. hours” (Phelps, Ralph, & p.44). assessed every 2
Taylor, 2017, p.44). 2. “to detect decreased hours.
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Secondary Nursing Diagnosis:
Risk for impaired skin integrity r/t physical immobility.
The patient will maintain
skin integrity.
The patient will not
sustain skin redness or
breakdown of greater
than 2cm in diameter by
the end of the shift.
2. “Auscultate for heart or adventitious breath 2. The client’s lungs
and breath sounds at sounds” (Phelps, Ralph, were
least every [2] hours” & Taylor, 2017, p.44). auscultated 4
(Phelps, Ralph, & Taylor, 3. “These measures times during the
2017, p.47). promote comfort, shift.
3. “Assist patient to a chest expansion, and 3. The client was
comfortable position, ventilation of basilar assisted to a
for example, by lung fields” (Phelps, comfortable
supporting the upper Ralph, & Taylor, 2017, position at every
extremities with pillows, p.44). encounter.
providing an overbed
table with a pillow to
lean on, and elevating
head of bed” (Phelps,
Ralph, & Taylor, 2017,
p.44).
1. “Change patient’s 1. “These measures The goal was met.
position at least every reduce pressure on 1. Client was
2 hours; follow turning tissues, promote repositioned every 2
schedule posted at circulation, and help hours.
bed side. Monitor prevent skin 2. Client’s linen was
frequency of turning” breakdown” (Phelps, changed once during
(Phelps, Ralph, & Ralph, & Taylor, 2017, the shift.
Taylor, 2017, p.322). p.322). 3. Client was placed on
2. “Keep linen dry, clean, 2. “Dry, smooth linens an air mattress.
and free from wrinkles help prevent
or crumbs” (Phelps, excoriation and skin
Ralph, & Taylor, 2017, breakdown” (Phelps,
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 p.322). Ralph, & Taylor, 2017,
3. “Use preventative skin p.322).
care devices, as 3. “to avoid discomfort
needed, such as foam and skin breakdown”
mattress” (Phelps, (Phelps, Ralph, &
Ralph, & Taylor, 2017, Taylor, 2017, p.322).
p.322).
Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

References

AACC. (2019). Blood urea nitrogen. Retrieved from https://labtestsonline.org/tests/blood-urea-nitrogen-bun

AACC. (2019). Creatinine. Retrieved from https://labtestsonline.org/tests/creatinine

AACC. (2019). Red blood cells. Retrieved from https://labtestsonline.org/tests/red-blood-cell-count-rbc

Friberg, E. E., & Creasia, J. L. (2016). Conceptual foundations: The bridge to professional nursing practice (6th ed.). St. Louis, MO.

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Lewis, S., Bucher, L., Heitkemper, M., & Harding, M. (2017). Medical-surgical nursing (10th ed.). St. Louis, MO.

Mayo Clinic. (2019). Acute respiratory distress syndrome. Retrieved from https://www.mayoclinic.org/diseases-

conditions/ards/symptoms-causes/syc-20355576

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD.

Sepsis Alliance. (2020). Testing for sepsis. Retrieved from https://www.sepsis.org/sepsis-basics/testing-for-sepsis/

Vallerand, A., & Sanoski, C. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA.

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