Subjective Data Objective Data
Subjective data A 65 years old male
Patient is unable to patient, known case of
explain his problem, left renal tumor. Came
because patient in ICU for the
intubated and management of
sedated. respiratory distress and
hypotension. Currently
GCS 3/15 with sedation
CIV Midazolam @
3mg/hr and CIV
Morphine @ 4mg/hr
onflow, Both pupils are
reactive to light and
equal in size 2mm.
Hemodynamically
unstable, CIV
Norepinephrine @
12mcg/min and titrate
according to MAP as
target MAP >65mmHg,
Afebrile and Sinus
tachycardia. On
ventilator support via
ETT, Mode V-A/C, PeeP
7, RR 20, FIO2 70% and
maintaining saturation
upto 95%. CVC line in
placed Rt IJ, Arterial line
in Lt radial inplaced. IVF
N/Saline @ 120ml/hr on
flow. OGT inplaced and
keep on passive
Diagnosis Goals Interventions Evaluation
Decreased cardiac Patient will be Attached cardiac :: Inotropic support
output related to maintain MAP >65 monitor ‘s leads and continue and
septic shock as with ionotropic continuously maintaining target
evidence by support in next 24 monitoring rhythm on MAP with inotropic
patient is on hours. monitor. 12 Lead ECG support. Further
inotropic support. done. CIV Nor nursing intervention
Epinephrine onflow @ and re-evaluation to
12mcg/min,(Titrating be continued.
according to target
MAP). Collaborate
with the other health-
care team regarding
various tests including
ABGs, cardiac
enzymes, chemistries,
echocardiograms, and
hemodynamic
monitoring.
Administer
maintenance
intravenous fluid and
medications as
prescribed, and
monitor effects.
Measure urinary
output hourly. Avoid
those drugs cause
hypotension.
.
drainage. Folyes
catheter inplaced, 50-
80ml/hr urine output
noticed. Skin intact no
bed sore noticed.
Foley’s catheter intact
output is low due to
AKI.