Microsoft word - critical+care+careplan.docx

INDIANA UNIVERSITY SCHOOL OF NURSING
BACCALAUREATE PROGRAM-BLOOMINGTON CAMPUS
S471—Restorative Health Related to Multi-System Failures: The Practicum
Weekly Patient Note

Name__Brittany Rowe___________________________

Patient Story/Background/History:
*****
Pt is a 55 year old male, who was found ‘down and out’. He presented with mental status changes and
bilateral chest infiltrates. On 10/29 he started having a fib, on 10/30 he had a NRB and on 10/31 he was put
on lasix to diuresis. On 11/1 he was intubated (CPAP at Fi02 100%) and had a bronch that found a dental
filling in the right lobe and it was removed. On 11/3 a cortrack was placed. On 11/4 he had decreased UOP
and was less alert. He was found to have wernickes encephalopathy and cholecysisitis. On 11/5 he possibly
went into septic shock, but with fluids, pressors and antibiotics he came out of it and was stable. On11/6 he
had an ERCP
He has an extensive ETOH history, drinking one-half-gallon a day. He also smokes and has seizures in the
past. His echo showed cardiomyopathy with an EF of 25%.
Special equipment/monitors:
Tele, ventilator, foley cath, cortrak, Right PICC, L hand 22g IV zassi, NIBP
All medications & monitoring (list 3 priority monitoring parameters per med):

Medication
Monitoring Parameters (choose top 3 priority) Ammonia levels, stool, mental status (high ammonia levels) BP, HR, fluid retention (lung sounds, UOP) Good job. What did you assess on this patient (prioritized)? Be specific about what you observe and do during your assessment. Assessment Area HR: 115 BP:110/68 O2:94% on 50% FiO2, RR: 34 T:98.2, Pain: unable to verbalize, and no behavioral cues Sinus tach,, S1 and S2 sounds, pulses +1 to +2, +1 edema right arm, +2 left arm, +2 scrotal edema, +3 bilateral feet, extremities warm and dry, cap refill <2 seconds, no JVD Lung sounds coarse throughout, ventilated (spontaneous), ventilator tube (size 8) 25 cm at teeth. Unable to verbalize if oriented. Spontaneous eye opening, obeys commands (squeeze hands and wiggle toes), with ETT = Glasgow 11. Pupils 2mm and moderate to react. Skin color appropriate for race except right forearm red and warm from previous IV (I was told). Mucous membranes dry with slough, Pressure wound on top of sacrum (II-III), deep purple, Braden:14 Abdomen firm and distended, hypoactive bowel sounds, LBP 11/6, Fecal bag on, stool watery, green and yellow (C diff), cortrak at 95cm, clamped good

What nursing interventions did you implement and why (group by patient problem)?
Use only the interventions that MOVE the patient to an outcome (no assess/check/monitor)

Patient Problem Amenable to Nursing Care
Interventions
Ventilator, suction every 2 hours and as needed, oral care every 2 hours, listen to lung sounds, administer antibiotics, suctioning HOB elevated, 02 monitoring, increase Fi02 before Hand hygiene, change dressing, administer antibiotics, oral care to prevent VAP, Point of care/insulin to control blood sugars draw and monitor labs VS, fill out and follow sepsis protocol, hibacleanse bath Osmolite (after procedure), replace electrolytes Gave bath, cleaned perineal area frequently Talked patient through everything, used patients name, put on TV, restraints/ativan on(if getting agitated), then taking restraints off when possible Turn q2, changed wound dressings, put on santyl, cleaned stool frequently, placed a zassi to prevent skin breakdown, foley cath to decrease moisture , suggest FFP/PRBC, monitor for bleeding Very complete What evaluation and changes in care did you determine are needed for the patient and why? In the morning we determined the tube feeding should be stopped (and no lactulose given) because the patient will need a procedure with anesthesia. Since the fecal bag came off a zassi was recommended to prevent skin breakdown. I noted the patient usually seemed alert so I turned on the TV so he had something to distract him. When he was agitated and going to pull out tubes we determined Ativan and wrist restraints were necessary. I also determined hydralazine should be held since his BP was at or below 110. I also noted the PICC dressing needed to be changed since it was over 7 days old. What care is going to be needed for this patient in the short and long term and why (ADL’s)? Short Term
Long Term
Skin care/turning- dressing changes-cleaning Smoking/ alcohol cessation- AA, rehab, group home Ventilation and Care-Oral care/suction Possibly dialysis if kidneys continue to fail Thiamine for Wernickes encephalopathy Family education about procedures


LABS
Lab Abnormality
What do you need to do as a nurse related to resolving the lab AND monitoring for complications of the lab? Monitor ECG, muscle weakness, urinary output Monitor I and O, urine color, skin turgor, daily weight, monitor Replace electrolytes, fluid restriction, tube feeding, restrict phosphate, administer anti-hypertensives Monitor I & O, urine, skin turgor, weight, lung sounds, Replace electrolytes, fluid restriction, tube feeding, restrict phosphate, administer anti-hypertensives Monitor I & O, urine, skin turgor, weight, lung sounds, Replace electrolytes, fluid restriction, tube feeding, restrict phosphate, administer anti-hypertensives Watch for muscle spasm, confusion, tingling, EKG, Give Ca through feeding or supplements, do bed and ROM exercises with pt Malnutrition, liver failure BM character, frequency, I&O, BP, watch for edema watch for edema, especially with this HF patient. Administer albumin, tube feeding to increase protein Limit morphine, monitor mental status changes, monitor for jaundice, monitor RBC, watch for bleeding, asterix, ECG Prepare pt for ERCP and cholesisostomey, teach family about alcohol cessation, hyperventilate, give lactulose, fluids (careful with kidneys), glucose checks, give FFP and protonix for anti ulcer, maintain tube feedings very excellent points esp. r/t MS Limit morphine, monitor mental status changes, monitor for jaundice, monitor RBC, watch for bleeding, asterix, ECG Prepare pt for ERCP and cholesisostomey, teach family about alcohol cessation, hyperventilate, give lactulose, fluids (careful with kidneys), glucose checks, give FFP and protonix for anti ulcer, maintain tube feedings Monitor skin and eyes for yellowing Limit morphine, monitor mental status changes, monitor for jaundice, monitor RBC, watch for bleeding, asterix, ECG Prepare pt for ERCP and cholesisostomey, teach family about alcohol cessation, hyperventilate, give lactulose, fluids (careful with kidneys), glucose checks, give FFP and protonix for anti ulcer, maintain tube feedings Malnutrition, liver failure Limit morphine, monitor mental status changes, monitor for jaundice, monitor RBC, watch for bleeding, asterix, ECG Prepare pt for ERCP and cholesisostomey, teach family about alcohol cessation, hyperventilate, give lactulose, fluids (careful with kidneys), glucose checks, give FFP and protonix for anti ulcer, maintain tube feedings Limit morphine, monitor mental status changes, monitor for jaundice, monitor RBC, watch for bleeding, asterix, ECG Prepare pt for ERCP and cholesisostomey, teach family about alcohol cessation, hyperventilate, give lactulose, fluids (careful with kidneys), glucose checks, give FFP and protonix for anti ulcer, maintain tube feedings Signs of acidosis, weakness, lethargy, deep rapid breathing, Monitor O2 stat, lung sounds, rate and depth of breathing, Administer O2, HOB>45 degrees, monitor for FVO (edema, I & O, lasix, Administer tube feeding to promote RBC formation, PRBC Alcohol-.> bone marrow O2 stat, cap refill, monitor fatigue, SOB, EKG, repeat HCT, O2 stat, cap refill, monitor fatigue, SOB, EKG Watch for bleeding in gums, nose, stool, hemopytysis Limit sticks, avoid IM’s, soft tip in oral, FFP, PRBC Watch for bleeding in gums, nose, stool, hemopytysis Limit sticks, avoid IM’s, soft tip in oral, FFP, PRBC
Again, very complete.
MEDICATIONS YOU GAVE—Scheduled and PRN (oral, injections, IVP, IVPB)
Medication (generic and
Pt remains infection  CNS s/s –headache,  Signs of infection‐ temp,  40mg=1tab oral daily or IV push Metronidazole Collagenase topical daily Skin breakdown itching , fever/chills temp (for allergic reaction, wound Insulin determir daily 12, Rise in cortisol Platelet, RBC, WBC Anemias other than CBC, bleeding, Platelet, RBC, WBC Anemias other than CBC, bleeding, fatigue failure, alcoholism, count will increase hypoglycemia protocol
Glucose chew

ALL CONTINUOUS IV SOLUTIONS AND CONTINUOUS IV DRIP MEDICATIONS
IV Solution or Drip/Rate
drink orally, tube feedings UOP, decrease hydration output, daily weight

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