NURSING CARE PLAN TEMPLATE

Name of Student: aisha Mohammed ID Number:H00372795

SECTION 1. PATIENT’S DATA:

Name of Patient: adam joseph
Age: 28 Gender: M Nationality: new zeland Date of Birth: 25-9-1991
Date of Admission: 13-10-2019
Medical Diagnosis: global ischemic stroke
secondary : drug overdose , acute kidney failure, cardiorespiratory arrest
HISTORY OF THE PATIENT:

Chief complaints:

Present history:

Un known patient brought by national ambulance after suspicion of taking of quetiapine and alcohol as patient
was found lying uphill in the mountain by police with empty bottle of alcohol and empty wraps of quetiapine
that were found besides him, so according to national ambulanace people was in respiratory distress and
tachycardia, ventilation in ambulance was secured, patient have had coffee ground vomiting in ambulance
before brought to emergency, in emergency patient collapsed had asystole as no pulse and blood pressure so
code blue announced. CPR started and patient ventilation secured and chest compression, 2 dose of adrenalin
given and patient achieved ROSC (resumption of sustained perfusing ) and then 2 dose of nalaxone were given
during resuscitation, patient intubated and IV fluid started and advised to send toxicology screen and admit in
ICU

Past history:
As per the family, the patient has been diagnosed with depression and is on treatment and has had
suicidal thoughts
no other history or any other family history.

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PHYSICAL ASSESSMENT FINDINGS:
Mention the major systems which the patient has significant findings.
Review of the specific (related) body system(s):

☒General:

Patient is bedridden since he was admitted to the hospital, with severe distress, patient under full
sedation and mechanical ventilation, unconscious, fully dependent, he was well groomed and has bad
odor of alcohol

☐Skin:

Pale skin, there is hives skin rashes in his left shoulder and his back with his left upper leg, skin is moist
and warm, no lesion, no sores, no edema

☐HEENT:

Head: patient is unconscious, has an cerebral edema

Ears: there is no ear discharge, no ear infection
Eyes: there is no response to the light, they are equal and no pupil dilation
Nose: there was a green discharge from the nose , normal sinuses
Throat: no erythema or any discharge, no sore throat

☐Breast:

Normal chest, symmetrical

☐Pulmonary:

Patient is apnea, ventilated and intubated, chest xrays showing surgical emphysema, right
pneumothorax, symmetric chest wall expansion, no chest wall tenderness

☒CV:

Patient had cardiac arrest, CPR done at ER , tachycardia, no murmur , elevated PT

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☐PVD:

normal pedal pulses, no femoral artery bruit, normal dorsalis pedis, no venous insufficiency, no
ulceration, no hair loss, no obvious varicose veins
☐GI:

Presence of vomiting coffee colored twice little amount

☐GU:

Acute kidney failure, no urethral discharge, no lesion, ulcers, rashes, no hematuria, patient if on
indwelling catheter

☐Endocrine:

normal weight, poor appetite as mother mentioned before , decreased in T4 (hypothyroidism)

☐Heme:

patient has decrease in Hct and hgb, patient developed sepsis

☐MSK:

Patient is bedridden, unconscious, no tenderness or swelling over the joints

☐Neuro:

Patient is ventilated and intubated , twitching movement of the head and hands, no planter reflexes,
GCS: scored 3

☐Psych:

Patient has been diagnosed with depression and has suicidal thoughts

SECTION II LAB AND DIAGNOSTIC TESTS

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Name of procedure Date Result Interpretation

WBC 23.78*10(3)mcl HI Indicates problems such as infection,

stress, inflammation, trauma, allergy
, viral or bacterial infection
PT 14.40 sec HI blood is taking longer than normal
to clot and may be a sign of many
conditions, including: Bleeding or
clotting disorder
Chloride lvl 110mmol/L HI indicates dehydration, but can also
occur with other problems that
cause high blood sodium, such as
Cushing syndrome or kidney
disease
Total protein 58gm/L LOW Indicates any of the following
health conditions: malnutrition.
malabsorption disorders, such as
celiac disease or inflammatory
bowel disease (IBD) liver disease.
kidney disease, such as nephrotic
syndrome or glomerulonephritis
Albumin Lvl 26.7 gm/L LOW indicates that there is liver disease or an
inflammatory disease.
Higher albumin levels may be caused by
acute infections, burns, and stress from
surgery or a heart attack
T4 Free 11.45 pmol/L LOW Indicate an underactive thyroid gland
(hypothyroidism)
CRP 166.6 mg/L HI High CRP level can indicates that
there’s inflammation or infection
pO2 Art 75.8 mmHg LOW It is the partial pressure (tension)
of oxygen in a gas phase in
equilibrium with blood indicate
blood hypoxia
PCT(procalcitonin) 23.56 ug/L HI A high level could be a sign of a
serious bacterial infection, such as
sepsis
Hgb 11.90 L Low hemoglobin count may indicate you
have anemia.
Hct 36.10 L The proportion of the blood that
consists of packed red blood cells,
low hematocrit is anemia

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 body isn't properly using or doesn't
glucose 9.1 H make the hormone insulin.

SECTION III MEDICATIONS

Medication Dose/route/ Classification and indication Side effects

name Frequency

Cefepime 1 vial 1 mg q8hr fourth-generation Abdominal or stomach

cephalosporin antibiotic cramps.
reserved to treat severe back, leg, or stomach
nosocomial pneumonia, pains.
infections caused by multi- bleeding gums,
resistant microorganisms
nosebleeds.
(e.g. Pseudomonas
aeruginosa) and empirical convulsions.
treatment of febrile dark urine.
neutropenia.
Mometason 1 app cream q24hr Corticosteroids skin rash,
e his medication is used to treat itching,
skin conditions such as burning,
eczema, psoriasis, allergies,
redness,
and rash
used to prevent and treat dryness,
seasonal and year-round
allergy symptoms (such as
stuffy/runny nose, itching,
and sneezing)
Beta 1 app ointment class of phytosterols nausea, indigestion,
is used for heart disease and
sitosterol q24hr
high cholesterol
gas, diarrhea,
use beta-sitosterol for or constipation.
enlarged prostate (benign
prostatic hyperplasia or BPH).

quetiapine Oral maintenance anti-psychotic Constipation,

used to treat certain drowsiness, upset
mental/mood conditions
(such as schizophrenia, stomach,
bipolar disorder, sudden tiredness, weight gain, b
episodes of mania or lurred vision, or dry
depression associated with mouth

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 bipolar disorder)
It may also improve your
mood, sleep, appetite, and
energy level.
Metronidaz 100ml 500mg IV antibiotics known as nausea, vomiting, loss
ole injection q8hr nitroimidazoles of appetite, stomach pain;
used to treat a variety of diarrhea, constipation;
infections. headache;
unpleasant metallic
taste;
rash, itching;

Pantoprazol 0.2 vial 8 mg q1hr proton pump inhibitors headache.

e used to treat certain stomach diarrhea.
and esophagus problems stomach pain.
(such as acid reflux). ... It nausea or vomiting.
helps heal acid damage to gas.
the stomach and esophagus,
dizziness.
helps prevent ulcers, and
may help prevent cancer of
the esophagus

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 Current IV infusions

Infusion Name Concentration, Amount/ Calculation Classification / Indication

Frequency Drop/Min

Sodium chloride 0.9% 500 ml indicated for extracellular

fluid replacement and in
the management of
metabolic alkalosis in the
presence of fluid loss, and
for restoring or maintaining
the concentration
of sodium and chloride ion
s
Dextrose 5% with 0.9% NaCl 2500 ml used to treat very low
104.17 ml\hr blood sugar
(hypoglycemia), most often
in people with diabetes
mellitus.
Midazolam 12ml benzodiazepines
2ml\hr short-acting hypnotic-
sedative drug with
anxiolytic, muscle relaxant,
anticonvulsant, sedative,
hypnotic, and amnesic
properties
Remifentanil 50ml short-acting synthetic
2ml\hr opioid analgesic drug
used for sedation as well
as combined with other
medications for use in
general anesthesia
Propofol 10 ml short-acting, lipophilic
Parenteral 2ml\hr intravenous general
anesthetic
used to help you relax
before and during general
anesthesia for surgery or
other medical
procedures. Propofol is
also used to sedate a
patient who is under critical
care and needs a
mechanical ventilator
(breathing machine).

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SECTION IV NURSING CARE PLAN:

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 SECTION IV - LIST OF NURSING DIAGNOSIS - (5 according to priority): List 5 diagnoses from

systematic analysis that incorporates complete diagnostic statements in PES (Problem Etiology

and Signs / Symptoms) format.

1. Ineffective Cerebral Tissue Perfusion related to cerebral edema and herniation in brain
as evidence by patient is unconscious (comatose), GCS scored 3, high ICP.

2. Impaired gas exchange related to destruction of alveolar walls as evidence by chest x-

ray secondary to surgical emphysema

3. Excess fluid volume related to impaired kidney function secondary to cardiopulmonary

resuscitation as evidence by decreased hematocrit and altered electrolytes

4. Risk for Ineffective Breathing Pattern related to alteration of O2 and Co2 ratio secondary
to pneumothorax and surgical emphysema

5. Risk for Decreased Cardiac Output related to kidney failure

From the above five choose the first three priority nursing diagnosis, and complete the nursing
care plan in ADPIE format on page 7.

Assessment data: Subjective data: Objective data: your assessment

Patient is unconscious un able to verbalize Changes in LOC, patient is

unconscious, 3 score of GCS , no

pupil reaction , Elevated

Temperature

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 ICP:18

vital signs, Bp:151\82

Nursing diagnosis 1 Ineffective Cerebral Tissue Perfusion related to cerebral edema and herniation in brain as

evidence by patient is unconscious (comatose), GCS scored 3, high ICP.

Objectives/Plan By the end 8 hours of nursing interventions the patient will be able to stabilize the Bp,

maintained ICP from 1 to 15 and would improve pupil reaction

1. Position with head slightly elevated 30-45° to educes arterial pressure by

promoting venous drainage therefore it might improve cerebral
Intervention/s perfusion.
2. provide quiet and relaxing environment, restrict visitors and activities to reduce
stressors, stress could increase the Bp and ICP
3. Closely monitor the neurological status and compare it with baseline data
4.closely monitor the blood pressure
5. Evaluate pupils for size, shape, equality, and light reactivity to determine whether the
cranial nerves are working
6. Decreases ICP by Improving venous return Minimizing intra thoracic pressure
7.Monitor Temperature and hemodynamics, including MAP and CPP
8. Administer supplemental oxygen as needed.
9. Administer medication as order such as Antihypertensives

Evaluation After 8 hours of nursing care the patient improved decreasing in ICP as evidence by

ICP:13, a Bp within normal range as evidence by BP: 125\67 and sluggish response to the

light

Assessment data: Subjective data: Objective data: your assessment

Patient is unconscious un able to verbalize RR:17cpm

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 chest xray: surgical emphysema

patient is on mechanical ventilator

Elevated BP: 151\82

Tachycardia 108

Abnormal arterial PH: 7.343

Nursing diagnosis 2 Impaired gas exchange related to destruction of alveolar walls as evidence by chest x-ray

secondary to surgical emphysema

Objectives/Plan By the end of 8 hours of nursing intervention the patient will be able to improved

adequate oxygenation of tissue, ventilation and blood gases within normal ranges
1. Position patient with head of bed elevated,

2. Monitor changes in the level of consciousness and mental status

Intervention/s

3. Monitor arterial blood gasses values as ordered.

4.suctioning as needed

5. Provide humidified oxygen as ordered.

6. Maintaining a patent airway

7. Administer mediation as doctor order such as bronchodilator

8.Auscultate breath sounds noting for area decreased airflow

9. Administer non invasive positive pressure

Evaluation After 8 hours of nursing care the patient improved normal arterial blood gases and

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 adequate oxygenation as evidence by normal ABG’s values pH: 7.40 HCO3:27.3mmol\L

pCO2:40.3 mmHg

Assessment data: Subjective data: Objective data: your assessment

Patient is unconscious un able to verbalize BP:151\82

Hct:36.10 L

hgb:11.90 L

Sodium level: 146 H

Chloride level: 110 H

Potassium Level: 3.47 L

Urine output: 300ml

Nursing diagnosis 3 Excess fluid volume related to impaired kidney function secondary to cardiopulmonary

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 resuscitation as evidence by decreased hematocrit and altered electrolytes
Objectives/Plan By the end of 8 hour of nursing intervention the patient will remain free of fluid

retention, complications of acute kidney function and restore normal blood pressure

1. Accurately record intake and output (I&O)

2. Weigh daily at same time of day
3. Assess level of consciousness
Intervention/s 4.Monitor Blood urea nitrogen and creatinine
5. Administer or restrict fluids as indicated.
6. Administer medication such as diuretics or antihypertensive
7. Insert indwelling catheter, as indicated.
8. Prepare for dialysis as indicated
9.Monitor for edema
10.Monitor level of glucose
Evaluation After 8 hours of nursing care the patient remain free of fluid retention , other

complications as evidence by absence of edema and normal blood pressure: 125\67

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REFERENCES:

Goyal A, Daneshpajouhnejad P, Bashir K. Acute Kidney Injury (Acute Renal Failure) [Updated
2019 Sep 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019
Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441896/

Hui C, Tadi P, Patti L. Ischemic Stroke. [Updated 2019 May 16]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK499997/

Khaku AS, Hegazy M, Tadi P. Cerebrovascular Disease (Stroke) [Updated 2019 Aug 3]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK430927/

Tran, Q., Mizumoto, R., & Mehanna, D. (2018). Management of extensive surgical emphysema
with subcutaneous drain: A case report. International journal of surgery case reports, 44, 126–
130. doi:10.1016/j.ijscr.2018.01.018

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