Care Plan 1

Student: Evelina Balzhyk Date: 01.21.2020

Course: NSG-430CC/Critical Care Instructor: Sheila Arnberger

Clincial Site: Banner Del E. Webb Medical Center Client Identifier: PR Age: 24

Reason for Admission:

PR was admitted into the Emergency Room on 12-28-2019 for bleeding from her gastro-jejunal tube site. GJ tube was placed on 07-28-2019
due to gastroenteritis. The GJ tube got removed on 12-29-2019 and patient has been on TPN since. PR had a central venous catheter inserted on
09-07-2018 due to procedures such as blood transfusions associated Postural Orthostatic Tachycardia Syndrome (POTS) and anemia; the port
was removed and replaced on 01-06-2020 due to sepsis, the current diagnosis.

Medical Diagnoses: Clinical Manifestation(s):

Sepsis is a condition caused by the body’s response to an infection, this Clinical Manifestations that PR experienced were respiratory rate
condition may be life-threatening. When an infection occurs, the body higher than 22, fever and shivering, and extreme pain (PR rated
will typically release chemicals to fight it, however, “Sepsis occurs when 8/10 pain).
the body's response to these chemicals is out of balance, triggering Common clinical manifestations that can be experienced during
changes that can damage multiple organ systems” (MayoClinic, 2018). sepsis are change in mental status, a systolic blood pressure less
People who are hospitalized or have chronic conditions are more than 100 mmHg, and sweaty skin (MayoClinic, 2018).
susceptible to sepsis, it is important to seek medical attention as soon as
signs and symptoms occur. Risk factors of sepsis are the
immunocompromised patients, patients who have previously received
antibiotics or corticosteroids, and those who have invasive devices
(MayoClinic, 2018). PR had an invasive devise, a central venous catheter.

Assessment Data

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

Subjective Data: Patient states that she feels weak and her pain is in the neck, back, and abdomen. PR says “the pain goes away and then
comes right back”.
VS: taken on 01.21.2020 at Labs: Diagnostics:
0800
Hgb (11.7-15.5): 8.5 PR came into the  CT Abd/Pelvis (1.19.2020 at 1400)
T : 36.5 C (L) hospital with bleeding Impression: internal slight effusions and mild
from her GJ tube, low bibasilar atelectasis versus pneumonia or
BP: 118/74
hgb could possibly aspiration.
HR: 129 bpm occur due to blood  Blood Culture (1.06.2020)= Klebsiella Oxytoca
loss. positive in blood culture
RR: 29 bpm
RBC (3.8-5.1): 3.16 The patient has a  Blood Culture (1.16.2020)= Enterococcus faecalis
O2 Sat: 94% on room air positive in blood culture
(L) history of anemia
Pain: 8/10 on scale of 0 to 10 which could indicate  Urine culture (1.19.2020)= Escherichia coli
pain. a low red blood cell positive in urine culture
VS: take on 1.21.2020. at 1100 count.

T: 36.6 C Glucose (<100): 110 The patient currently

(H) has an infection and is
BP: 109/66 bed-ridden, these are
HR= 123 bpm both indicators of a
high glucose level.
RR: 29 bpm
Hct (35-47%): 25.6 PR has anemia, this is
O2 Sat: 95% on room air
(L) an indicator for low
Pain: 6/10 on scale of 0 to 10. Hct.
Creatinine (0.6-1.1): A low creatinine level
0.54 (L) could be cause by
muscle wekness and
immmobility, this is
what the patient is

2
 experiencing.
Mch (27-34): 26 pg Low mch could
(L) possibly be caused by
anemia and
malnutrition, PR was
previously diagnosed
with protein
malnutrition.
Calcium (8.6-10.3): Low calcium coud be
7.9 (L) caused by
malnutrition. The
patient is also
fatigued, that could be
caused by calcium.
(Lewis, S. L., Bucher,
L., Heitkemper, M.
M., & Harding, M.,
2017).

3
Assessment: Orders:
Neuro: The patient is alert and oriented x4. Pupils are 3 mm bilaterally  Patient teaching on importance of ambulation
and are regular bilaterally. PR’s glasgow coma score is 15.  Monitor I&O’s
Communication and behavior are appropriate. Patient’s affect was  Continuous pulse oximetry
blunt.  Vital signs per protocol
Respiratory: Lung sounds are present and clear in all lobes bilaterally.  Continuous cardiac monitoring
Patient occasionally coughs. Respirations are rapid, at 29 bpm.  Foley catheter protocol
 Central venous catheter care
Cardiac: Normal S1 and S2 sounds. No murmur present. patient has no
edema in lower extremities. Patient’s rhythm is sinus tachycardia, at
129 bpm. Radial and dorsalis pedis pulses are +2 bilaterally, slightly
diminished. Capillary refill is less than 2 seconds, nail beds are pink.
GI: Bowel sounds are present. Abdomen is soft and non distended.
Dressing from previous GJ tube insertion dry, intact, non-odorous, with
no drainage.
GU: The patient has an indwelling urinary catheter. The urine is yellow,
clear, and odorless. Intake was 450 ml and output was 375 ml.
Muscoloskeletal: No joint swelling noted on all joints, no compression
deviced or compression stockings. Weak ROM in lower extremities
(did not want to move upper extremities).
Integumentary: Generalized pallor, otherwise appropriate for ethnicity.
Skin is dry and warm. Skin turgor is normal.
Lines: PR has central venous catheter in the right internal jugular, it is
patent and intact. She also has an indwelling urinary catheter.
Diet: Patient is on TPN. Spesific type of TPN and amount not recorded.

4
 Medications
ALLERGIES: Latex, Sulfa, Chlorhexidine, Pantaprazole, PCN, red dye, Xolair, Acetaminophen, Glycerin, Lovenox, Tramadol, Zantal,
Bactrim, Clindamycin, Contrast Dye, Macrobid, Cephazolin, Keflex

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Flamotidine 20 mg/2 IV push Q12h Patient had gastroenteritis. Confusion, dizziness, Assess for
ml This medication is a short- drowsiness, hallucinations, epigastric or
term treatment of headache, arrhythmias, abdominal pain and
duodenal ulcers, GERD, constipation, diarrhea frank or occult
indigestion, and sour blood in the stool,
stomach. emesis, or gastric
aspirate
Monitor CBC with
differential
periodically during
therapy.
Levofloxacin 750 IV Q24h Treatment of bacterial Elevated intracranial Observe patient for
mg/150 piggyback infections. Patient was pressure, seizures, signs and symptoms
ml diagnosed with sepsis, agitation, anxiety, of anaphylaxis
sepsis is caused by confusion, depression, (rash, pruritus,
bacterial infections. dizziness, drowsiness, laryngeal edema,
hallucinations, wheezing). Notify
headache, insomnia, physician
nightmares, paranoia, immediately if this
tremor occurs.
Meroperem 1 gr IV Q6hr This medication provides Seizures, dizziness, Assess for infection
piggyback bactericidal action against headache, apnea, diarrhea, (vital signs;
susceptible bacteria. It nausea, vomiting, thrush appearance of
5
 acts against gram-positive wound, sputum,
bacteria such as E.coli. urine, and stool;
Patient’s urine culture was WBC) at beginning
positive for E.coli. of and throughout
therapy. Determine
previous use of and
reactions to
penicillins.
Latanoprost 1 drop in Opthalmic qHS This patient has glaucoma Local irritation, foreign This patient has
each eye and is taking eye drops for body sensation, increased open angle
the treatment of it. eyelash growth, increased glaucoma. We will
brown pigmentation in the monitor for
iris increased pressure
in the eyes. We will
also monitor for
irritation and
redness around the
eye after giving the
eye drops. We will
monitor the patient
for reactions to the
medication as well
as ask about any
foreign body
sensation.
Benzonatate 100mg/1 PO TID This medication is used Headache, mild dizziness, Assess frequency
cap for relief of nonproductive sedation, nasal congestion, and nature of
cough due to minor throat pruritus, hypersensitivity cough, lung sounds,
or bronchial irritation reactions. and amount and
from inhaled irritants or type of sputum
colds. Patient was produced. Unless
coughing and this contraindicated,
medication was used to maintain fluid

6

Goal
Client or family focused.
Priority Nursing Diagnosis
Activity intolerance related to immobility as evidenced by generalized weakness.
This has been selected as the priority diagnosis because activity intolerance is a concern for physical needs which is the first tier in Maslow’s
Hierarchy of Needs.
Patient will regain and
maintain muscle mass and maintain muscle mass and need for activity.
strength.
(Phelps, Ralph, & Taylor,
2017).
decrease the cough.
Nursing Diagnoses and Plan of Care
Expected Outcome Intervention(s)
Measurable, time-specific, Nursing or interprofessional
reasonable, and attainable. interventions.
Patient will regain and 1. Discuss with patient the
strength by the time of 2. Identify activities that
discharge. patient considers desirable
and meaningful.
3. Monitor physiological
responses to increased
(Phelps, Ralph, & Taylor, activity (including
2017). respirations, pulse oximetry, patient a greater sense of
heart rate and rhythm, and
blood pressure). Document
intake of 1500–
2000 mL to
decrease viscosity
of bronchial
secretions.
(Vallerand, A. H., Sanoski, (Vallerand, A. H.,
C. A., & Deglin, J. H., Sanoski, C. A., &
2017). Deglin, J. H.,
2017).
Rationale Evaluation
Provide reason why intervention Was goal met? Revise the
is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
1. Lack of activity causes 1. Goal was met.
physical deconditioning Patient admitted that she
and may also have a needs physical activity
negative impact on to prevent further
psychological well-being. complications.
2. Engaging patient in 2. The patient shared
activities that have about her favorite
personal meaning gives the physical activities and
the desire to get back to
independence and may them
motivate atient to continue 3. The patient’s
7
 the time after each period of dveloping tolerance. response to activity was
exercise. Wait 5 minutes 3. Values should return to monitored and responses
and measure physiologic normal within 5 minutes or were measured.
responses. less.

(Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,

2017). 2017).

Secondary Nursing Diagnosis:

Risk for acute pain related to biologic injury agent- sepsis.

This has been selected as the secondary diagnosis because pain is a concern for physical needs which is the first tier in Maslow’s Hierarchy of
Needs.
Patient will help develop a Patient will help develop a 1. Assess patient’s signs 1. Assessment allows for 1. Goal was met. Patient’s
plan for pain control. plan for pain control by and symptoms of pain, and care plan modification, as signs and symptoms were
time of discharge. administer pain needed. assessed and appropriate
medication, as prescribed. 2. Although pain is medication was provided.
Monitor and record the subjective, when using the 2. Goal was met, a pain
medication’s effectiveness scale you can compare the scale was used to assess
and adverse effects. patient’s perception of and compare the pain
2. Use a pain scale when pain from one assessment levels.
assessing pain. to another. 3. Goal was met, a
3. Consider the services of 3. Patients who remain psychiatric professional
psychiatric mental health helpless, unmotivated, was contacted and a
professionals to help uncooperative, and realistic plan was
patient and staff members manipulative are self- established.
establish a realistic plan to destructive. Underlying
resolve the problem. causes should be explored.
8
 (Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,
2017). 2017).

References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of

Clinical Problems (10th ed.). St. Louis, MO: Elsevier.

“Sepsis.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 16 Nov. 2018, www.mayoclinic.org/diseases-

conditions/sepsis/symptoms-causes/syc-20351214#.

Ralph, S. S., Taylor, C. M., & Phelps, L. L. (2017). Nursing diagnosis reference manual. (10th ed.). Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkins.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's Drug Guide for Nurses (15th ed.). St. Louis, MO: Elsevier