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Cduc Gnrs 588 Comprehensive Care Plan 1
Cduc Gnrs 588 Comprehensive Care Plan 1
Cduc Gnrs 588 Comprehensive Care Plan 1
Colleen E. Duckworth
ASSESSMENT DATA:
1. History of Present Problem:
The patient currently has respiratory failure, or acute lung failure (ALF), and left-sided
pneumonia with pleural effusion. He has a history of non-small cell lung cancer (Non-SCLC). On 7/24,
he was seen by his primary care provider with pain and stiffness in his right hip status post fall. At that
time, he had a hip x-ray done which revealed cancerous lesions on the right pelvis. This prompted a
bone scan, done on 8/2, showing numerous lesions in pelvis, ribs, and spine. These results are evidence
for the patient’s new diagnosis of poorly differentiated metastatic Non-SCLC. The patient presented to
the emergency department on 8/29 with hypoxia, oxygen saturation of 88%, tachypnea, and tachycardia
and was then admitted to the ICU. His condition has worsened since then. His white blood cell count has
medication, and vasopressors. His left arm is restrained to keep him from pulling out his endotracheal
tube (ETT). He has been restless and responsive to pain. He has had occasional PVCs with post
ventricular contractions. The patient has a Foley catheter and a fecal containment device. He had watery
diarrhea overnight, and a stool culture to rule out C. difficile was sent. The patient has an OG tube, but
he was placed on an NPO order due to a scheduled stent procedure for today. The night nurse reports
that the procedure may be cancelled. He is scheduled for a diagnostic bronchoscopy and thoracentesis
today. He is supposed to transfer to a Scripps hospital to start chemotherapy in the next week.
Hypertension
Hyperlipidemia
Diabetes mellitus
What is the relationship of your patient’s past medical history (PMH) and current medications? Which medications treat
which conditions?
PMH Home Medications Pharm. Classification Expected Outcome
1. hypertension 1. amlodipine 1. calcium channel blocker, 1. A reduction in systolic, diastolic,
2. hyperlipidemia 2. losartan potassium antihypertensive and mean arterial blood
3. diabetes mellitus 3. atorvastatin 2. angiotensin II receptor pressure. It does this by blocking
4. CVA with right calcium antagonist, calcium influx across cardiac and
sided deficit 4. gemfibrozil antihypertensive vascular tissue membranes,
5. insulin (regular) 3. antilipemic, HMG-CoA which reduces coronary and
6. insulin glargine reductase inhibitor, statin peripheral vascular resistance,
7. insulin lispro 4. antilipemic, fibrate increases coronary blood flow
8. gabapentin 5. short-acting insulin, and oxygen delivery, and
antidiabetic increases cardiac output.
6. long-acting insulin, 2. A reduction in hypertension
antidiabetic through vasodilation and
7. rapid-acting insulin, inhibition of sodium and water
antidiabetic retention. It does this by blocking
8. GABA neurotransmitter angiotensin II receptors.
analog 3. A reduction in LDL and total
triglyceride and an increase in
(Shields, Fox, & Liebrecht, plasma HDL. It does this by
2018) inhibiting hepatic production of
cholesterol and increasing LDL
receptors.
4. A reduction in total triglyceride
and LDL cholesterol, and an
increase in HDL. It is useful in
patients who have not had
success with diet. It does this by
decreasing VLDL and
triglyceride synthesis.
5. Lowered blood glucose levels. It
does this by stimulating
peripheral glucose uptake of
skeletal muscle and fat,
enhancing protein synthesis and
conversion of glucose to adipose
tissue, and by inhibiting,
lipolysis, proteolysis, and
gluconeogenesis.
COMPREHENSIVE NURSING CARE PLAN 4
Vital Signs 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700
Noninvasive Blood Pressure (NIBP) (Left Arm) 70/38 149/50 174/59 142/59 140/60 130/74 128/60 147/69 166/70 154/6
6
Mean Arterial Blood Pressure (MAP) 49 83 97 87 87 93 83 95 102 95
Pulse Rate 101 88 87 90 89 80 88 80 89 85
Respiration Rate (RR) 16 18 20 18 20 16 18 20 15 20
% O2 Saturation (SpO2) (ETT) 94 97 96 97 100 94 97 99 98 100
Temperature (R axillary) 99.4 99.4 99.4 99.4 99.4 99.2 99.3 99.2 99.2 99.0
Other 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700
Pain Level (CPOT) 0 0 0 0 0 0 0 0 0 0
Sedation Level (RASS) -2 0 +1 0 +1 -1 0 0 +1 0
Blood Glucose (POC) 121 111 107 107 108 98 94 95 80 78
Intracranial Pressure (ICP) N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Hemodynamic 0800 0900 1000 1100 1200 Ventilator Settings IV Fluids
Monitoring
Arterial Blood 63/34 150/53 184/75 145/55 150/53 Type Rate/ Site
Pressure (ABP) Lactated 999 ml/hr/ Right
Central Venus N/A N/A N/A N/A N/A Mode: VTPC/CMV ringers 1,000 AC Peripheral
Pressure (CVP) mL IV bolus IV 20 g
Pulmonary Artery N/A N/A N/A N/A N/A once
Pressure (PAP) Rate: 16
Pulmonary Artery N/A N/A N/A N/A N/A
Occlusion Pressure
(PAOP)
Cardiac Index N/A N/A N/A N/A N/A
Cardiac Output (CO) N/A N/A N/A N/A N/A TV: 500 Sodium 10 mL/hr/Left IJ
Hemodynamic 1300 1400 1500 1600 1700 chloride CVC Triple
0.9% (TKO) Lumen
Monitoring Continued FiO2: 60%
Arterial Blood 147/68 139/62 171/71 173/74 165/59
Pressure (ABP)
Central Venus N/A N/A N/A N/A N/A
Pressure (CVP) PEEP: 8
Pulmonary Artery N/A N/A N/A N/A N/A
Pressure (PAP)
COMPREHENSIVE NURSING CARE PLAN 5
Pulmonary Artery N/A N/A N/A N/A N/A PS: N/A Sodium Intermittent
Occlusion Pressure chloride flushes, Right
(PAOP) 0.9% Radial ART
Cardiac Index N/A N/A N/A N/A N/A
Cardiac Output (CO) N/A N/A N/A N/A N/A
Intake (mL per shift) Output (mL per shift)
Intake/Output
Oral Enteral IV TOTAL Urine BM Emesis Drains TOTAL
Shift Total N/A N/A 2348 2348 610 1000 (3 N/A N/A 1610
episodes of
liquid
diarrhea
this shift)
Please state why there is a significant difference in the I/O (if any): The patient’s intake is significantly higher than output this
shift, with a difference of 738 mL. The patient is taking vasopressin, an antidiuretic hormone, which explains why there is less
urine output (Shields et al., 2018).
Rhythm: Regular
R. Lung Clear upper and middle breath sounds, Diminished lower breath sounds, Chest rise higher on
the right than left
L. Lung Absent upper and lower breath sounds
Capillary Refill <2 seconds
Skin Color/ Normal for ethnicity, warm, no tenting, trace edema in right upper and lower extremities
Temp
Cardio- Apical Pulse Normal, 80 bpm
vascular
Heart Sounds Normal S1 and S2
Peripheral Normal
Pulses
Oral Mucosa Dry, Several ulcers on gums, lips, and tongue, ETT in place, Frequent oral care provided by
RT
Tongue Dry, Ulcerations
Abdomen Soft, non-distended, normoactive bowel sounds
Nutrition NPO since this midnight
Gastro-
Tube Feeding Current Rate: _N/A__________ Goal Rate: _N/A____________
intestinal
Residuals: N/A_ Type: ☐ N/A ☐ NGT ☐ PEG ☐ J-tube ☐x OG-tube, not in
use, placed on 9/1, 16 French, secured at the teeth at 26
Bowel Sounds Hyperactive in all four quadrants
Bowel Last BM date: Today_____
Movement
Urination Through indwelling Foley catheter
Urine Color Amber
Urine Clear
Genito- Character
urinary Urine (ml) 610, Average 50 mL/hr
Urinary Insertion date: 9/1, no signs of infection
Catheter
Skin Color Redness without blanching
Skin Integrity At risk
Skin Wound/ 5x5 cm area on sacral region, covered by Mepilex sacral dressing
(wounds) Ostomy
Insertion Site(s) Right AC Peripheral IV, Left IJ central line, Right radial ART line
IV Assessment No signs of phlebitis, no redness, inflammation, or purulence
IV Fluids Normal saline & lactated ringers
Musculo- Describe Soft-restraint applied to left wrist, 1/1 strength with flicker of intention in right upper and
skeletal abnormalities: lower extremities r/t previous CVA
Psychosocial Assessment
Marital status Married
Education level Medical doctor
Social resources Lives with son, son visited the patient during the shift
Psychosocial Spiritual resources Unknown, unable to assess
History Occupation Hematologist
Employment Retired
Smoking 50 pack year smoking history, quit for 3 years, ¼ ppd in last year
Alcohol None
Recreational Drugs None
Spiritual Assessment
COMPREHENSIVE NURSING CARE PLAN 7
Spiritual
Spiritual Integrity 1) Look: (Signs of Meaning, Relationships, Hope and Joy)
Distress
Presence of….. Provide checkmark in either box for each criteria Absence of….
X Family, friends, visitors, wedding ring, photographs
Cards, letters, phone calls, flowers, pets X
Attention to personal care and appearance X
Work, projects, hobbies, music, books, tapes X
Newspapers, magazines, television, radio X
Special dress, prayer cap, head scarf, cross X
Articles of faith, pictures, statues, rosary, star X
Books of faith, Bible, Koran, Torah prayers X
Smiles, motivation, coping skills, healthy lifestyle X
Uses the observations listed above to begin your Spiritual Assessment
Acknowledge and inquire about photographs, cards, flowers, visitors
Acknowledge and inquire about hobbies, books, television/newspaper content
Acknowledge strength and inquire about profession
Acknowledge and inquire about articles of faith & religious preference
Acknowledge and inquire about mood (physical and psychological)
With your client as your guide, and after a sense of trust and connectedness have been established, continue with the assessment.
Phrase your questions and indirect statement in ways that convey your genuineness, style, and comfort.
I wasn’t able to ask any of these questions to the patient directly, because he was sedated and on a ventilator.
The best response I was able to get was eye contact. The patient’s son came to visit the patient, and the patient had a
more positive response to him; with shaking and nodding his head. Unfortunately, the son was not able to stay for
very long, and I wanted to give them private time. I would have liked to have asked the patient or his son if he knew
more about the patient’s goals, things that make him happy, where his sources of strength and refuge are, and if he
Spiritual Integrity Listen: (Actively listen for signs of meaning, relationships, hope, and joy) Spiritual Distress
**Provide checkmark in each box that is applicable:
Pt verbalizes... Pt verbalizes…
Patient is unable to verbalize any of these concepts.
Sense of purpose and meaning My life has no meaning
Source of pride & accomplishment Guilt, if only….I should have
Source of joy & happiness Sense of sadness and despair
Future Goals and desires Lack of motivation
Hope and Courage Hopelessness “What is the use?”
Interest in world & concern for others Lack of concern for others
Personal Strengths Powerlessness I am useless.
Connection to others Loneliness and isolation
Connection to a higher source Helplessness, anxiety, fear
Religious affiliation “This is not fair. Why me?”
Request for special diets, clergy “Why am I being punished?”
Appreciation for nature Apathy
Ability to adapt to changes Inflexibility
2. Nursing Diagnosis: Analyze the data, and if appropriate, select one of the following nursing diagnoses.
Potential for Enhanced Spiritual Well-Being
Spiritual Distress
COMPREHENSIVE NURSING CARE PLAN 8
Hopelessness related to loss of control and terminal illness as evidenced by anxiety, agitation, and isolation (Ackley, Ladwig,
x
& Flynn Makic, 2017)
Other
3. Plan: Develop a short-term goal and a long-term goal for your client.
ST Goal: The client will show reduced anxiety and agitation by exhibiting no higher than a +2 RASS score throughout the shift.
LT Goal: The client will answer through yes or no questions whether he has any goals in life that he still wants to accomplish before he
passes, and he will have time to reflect on these goals and think of a how to implement them by time of discharge.
4. Interventions: Identify the specific nursing interventions you will use with your client.
X Be present.
X Establish a therapeutic relationship conveying respect, warmth, empathy and genuineness
Active listening.
Assist client to identify strengths, supports, and interconnections.
X Instill hope.
X Use of touch, if client is comfortable with closeness.
X Provide an environment conductive to reflection, prayer, and spiritual growth.
Provide an environment conductive to client’s beliefs (food, ceremonies.)
Provide religious articles as requested.
Support client in search for meaning and purpose in life, illness, and death
Support client in search for a relationship with a higher power.
Pray with the client.
X Pray for the client.
X Promote private time with people who are significant in client’s life.
X Be available and approachable to assist client with meeting spiritual needs, and making spiritual choices.
Collaborate with chaplain or spiritual leader.
X Other: Assess for pain and provide pain medication (Ackley et al., 2017)
X Other: Encourage the patient’s son to come back to visit frequently, since it improved the patient’s response and mood
(Ackley et al., 2017).
5. Evaluation: Evaluate the client’s progress towards the goals.
(Note: Each person’s spirituality is highly variable, individual, and ever changing!)
ST Goal: The goal was met; the patient’s highest RASS score was +1 throughout the shift.
LT Goal: I expect the patient to meet this goal if his sedation is not too heavy throughout his entire discharge, because it is an appropriate
time to think of what he would like to do in life before he passes. I expect that he will an environment conducive to this, visitors, and
encouragement throughout his hospital stay.
**This Client Spiritual Assessment Tool (CSAT) was adapted from: Hoffert, D., Henshaw, C., & Mvududu, N. (2007). Enhancing the ability of nursing
students to perform a spiritual assessment. Nurse Educator, 32(2), 66-72.
What vital sign data are relevant that must be recognized as clinically significant?
What lab results are relevant that must be recognized as clinically significant to the nurse?
Lab Order(s): Current Values: Previous Values: Clinical Significance of Lab Values: Why was this test
(Normal Range) (N/H/L) N/H/L) ordered, and what is the significance of the value? Are
N = Normal N = Normal there any trends (improved, worsened, stable)?
H = High H = High
L = Low L = Low
COMPREHENSIVE NURSING CARE PLAN 10
Patient Family Education: This contributes to immunosuppression, report nausea, vomiting, muscular weakness and pain, avoid sources
of infection
Nursing implications/actions: Give over 2 minutes, report signs of Cushing’s syndrome
Generic Name: filgrastim Trade Name: Zarxio
Classification: Hematopoietic growth factor, Dose: 480 mcg Route: SC Frequency/ Rate: q A.M./ continuous
antineutropenic
Pt. Specific Indications: This helps treat chemotherapy induced neutropenia and mobilizes blood stem cells
Mechanism of Action: This regulates production of neutrophils within the bone marrow
Contraindications: ARDS, Do not give while currently receiving chemotherapy
Side Effects: ST segment depression, chest pain, anemia, cough, Adverse Effects: dizziness, fatigue, rash, hyperuricemia,
dyspnea, bone pain anemia, thrombocytopenia, increased ALP
Patient Family Education: report bone pain
Nursing implications/actions: Stored in refrigerator, assess for bone pain, monitor CBC, discontinue if neutrophil count exceeds
10,000/mm3
Generic Name: heparin sodium Trade Name: Hepalean
Classification: Anticoagulant Dose: 5,000 Route: SC Frequency/ Rate: q 12 hrs/ 2 mL/min
units (in 1 mL)
Pt. Specific Indications: The patient has a moderate VTE risk level
Mechanism of Action: Affects the clotting cascade, blocks to conversion of prothrombin to thrombin and of fibrinogen to fibrin
Contraindications: Hypersensitivity, active bleeding, suspected intracranial hemorrhage
Side Effects: fever, chills, rash, numbness and tingling in hands Adverse Effects: spontaneous bleeding, thrombocytopenia,
and feet, nasal congestion, conjunctivitis, hyperkalemia, bronchospasm, anaphylactoid reactions
suppressed renal function, rebound hyperlipidemia
Patient Family Education: Protect from injury, report chest pain, dark urine, bleeding oral mucosa
Nursing implications/actions: Monitor vital signs, report fever, drop in blood pressure, tachycardia, observe injection sites for signs
of infection, alternate injection sites, monitor coagulation tests and CBC
Generic Name: metronidazole Trade Name: Flagyl
Classification: antitrichomonal, amebicide, Dose: 500 mg Route: IVPB Frequency/ Rate: q 8 hrs/ 100 mL/hr
antibacterial
Pt. Specific Indications: For treatment of pneumonia and suspected C. difficile infection
Mechanism of Action: Has trichomonacidal, amebicidal, and antibacterial activity, acts on gram-negative anaerobic bacteria and
Clostridia
Contraindications: hypersensitivity, new abnormal neurologic signs
Side Effects: polyuria, nausea, vomiting, diarrhea, dry mouth, Adverse Effects: candida, flattening of T waves
confusion, insomnia, drowsiness
Patient Family Education: Urine may be dark, but this has no clinical significance, report candidal overgrowth on tongue
Nursing implications/actions: Check y-site compatibility, monitor for signs of seizures, monitor for sodium retention, report
candidiasis, repeat stool culture, monitor WBC counts
Generic Name: vancomycin hydrochloride Trade Name: Vancocin
Classification: antibiotic, glycopeptide Dose: 750 mg Route: IVPB Frequency/ Rate: q 12 hrs/ 250 mL/hr
in NS 250 mL
(3 mg/mL)
Pt. Specific Indications: For treatment of pneumonia and suspected C. difficile infection
Mechanism of Action: inhibition of cell-wall biosynthesis, alteration of cell-membrane permeability and RNA synthesis, for gram-
positive bacteria
Contraindications: hypersensitivity
Side Effects: hypotension, chills, warmth, nausea, rash Adverse Effects: nephrotoxicity, rash, chills, fever,
hypotension shock-like state, anaphylactoid reaction with
vascular collapse, leukopenia
Patient Family Education: Full course must be completed, may cause ringing in ears
Nursing implications/actions: Check y-site compatibility, monitor blood pressure and heart rate, monitor I&O, monitor renal
function tests
Generic Name: fentanyl citrate Trade Name: Sublimaze
Classification: analgesic, narcotic Dose: 2500 Route: IV Frequency/ Rate: continuous/ 0-20
mcg/250 mL mL/hr
infusion (10
COMPREHENSIVE NURSING CARE PLAN 13
mcg/mL, 0-200
mcg/hr)
Pt. Specific Indications: For analagosedation/analgesia and sedation
Mechanism of Action: narcotic agonist
Contraindications: hypersensitivity, substance abuse history, MAO inhibitor use in the last 14 days, significant respiratory
compromise
Side Effects: respiratory depression, reduced alveolar ventilation, Adverse Effects: circulatory depression or arrest,
sedation, euphoria, diaphoresis, nausea, vomiting, constipation, bronchoconstriction, respiratory depression or arrest, muscle
flatus, rash rigidity
Patient Family Education: Avoid hazardous activities
Nursing implications/actions: Check compatibility, monitor vital signs, watch for muscle rigidity and weakness, respiratory
depression could last longer than analgesia, have intubation equipment, Black box warning
Generic Name: insulin regular Trade Name: Humulin R, Novolin R
Classification: short-acting insulin, Dose: 100 units Route: IV Frequency/ Rate: continuous/ 0-60
antidiabetic in NS 100 mL mL/hr
(0-60 units/hr)
Pt. Specific Indications: Promotion of intracellular shift of potassium, regulation of blood glucose, and for counteraction of
hyperglycemia from norepinephrine use
Mechanism of Action: Stimulation of peripheral glucose uptake of skeletal muscle and fat, enhancement of protein synthesis and
conversion of glucose to adipose tissue, and inhibition of lipolysis, proteolysis, and gluconeogenesis
Contraindications: hypersensitivity
Side Effects: nausea, sweating, palpitations, tachycardia, Adverse Effects: anaphylaxis, coma, urticaria,
weakness, fatigue, hypothermia lymphadenopathy
Patient Family Education: blood glucose needs to be checked regularly
Nursing implications/actions: Check compatibility, monitor I&O, blood pressure, blood glucose
You currently have ALF, related to metastatic non-SCLC and left-sided pneumonia and pleural
effusion. Having ALF means that your lungs are not able to obtain oxygen and expel carbon dioxide on
their own requirements (Urden et al., 2018). It was likely caused by the malignancy of non-SCLC,
which classifies it as extrapulmonary ALF (Urden et al., 2018). Your natural drive to breathe, muscle
strength, normal pulmonary function, and elasticity of your chest are decreased. You have more
resistance that you have to work against to breath, and you have greater oxygen needs (Urden et al.,
2018). The demand that your tissues had for oxygen was not met when you were first admitted, which is
why hypoxia and hypoxemia developed (Urden et al., 2018). Currently, your arterial blood gas labs are
normal, which means that we have been able to correct some of your impaired gas exchange with the
use of the mechanical ventilator (Urden et al., 2018). Treating the underlying cause will require
treatment of non-SCLC, which you are scheduled to have beginning next week if we can get you stable
enough to do so (Urden et al., 2018). It has not been ordered, but medications that help expand your
airways would help with WLF (Urden et al., 2018). Positioning you on your right side would help, since
your left lung is the most involved; however, I have been told that you don’t like to be on that side
because of the flaccidity from your previous stroke. We can also elevate the head of the bed to 30 and 45
degrees, sedate you to control anxiety and provide plenty of rest to minimize use of oxygen (Urden et
COMPREHENSIVE NURSING CARE PLAN 15
al., 2018). We can give you IV fluids and provide suctioning to promote clearance of your secretions
(Urden et al., 2018). Unfortunately, the prognosis of your lung condition is poor, with one-third of
patients with ALF on a ventilator pass away in the hospital (Urden et al., 2018).
Your pneumonia is a bacterial infection in your left lung, correlated to your non-SCLC, and
compounded by your history of cigarette smoking, inhalation, passage of organisms down into your
airway through increased saliva secretions, intubation/ventilation, being in a supine position, from
having a depressed immune system, or through a reactivation of previous infection (Urden et al., 2018).
Lungs have different types of normal bacteria, but a stressful event, such as your chronic illness, harmful
bacteria invade and outgrow the normal bacteria (Urden et al., 2018). The infection contributes to
inflammation, which makes the small blood vessels in your lungs, called capillaries, more susceptible to
fluid accumulation and transfer through the vessel walls. A pleural effusion is a common complication
of pneumonia, because fluid from those capillaries finds its way into the pleural space, which is the
space between your lungs and the cavity in which your lungs live (Urden et al., 2018). Pus accumulation
also occurs in the small sacs in your lungs, called alveoli, which is where oxygen transport to the blood
normally occurs. The pus makes breathing more difficult and it makes your lungs have a harder time
expanding and contracting (Urden et al., 2018). Some of the symptoms and signs you have had since
you were admitted to the hospital are related to pneumonia. You have experienced not being able to
breath or breathing too quickly, coughing, and low oxygen delivery to your tissues (Urden et al., 2018).
We have tried to mediate these affects by placing a tube down your lungs and having a machine help
you breathe with mechanical support and supplemental oxygen. Your laboratory results have also
showed reduced white blood cells, which is a sign of pneumonia. We expect that the antibiotics you are
currently taking should help cure the infection. We cultured your blood which showed no growth, and
we are waiting on your lung fluid cultures to give us more information on the cause and status of your
infection. Once we find out these results, we will be able to change your antibiotics to something more
COMPREHENSIVE NURSING CARE PLAN 16
specific, if needed. The prognosis of pneumonia in conditions similar to yours is a mortality rate of 50%
(1) Impaired gas exchange related to alveolar hypoventilation, as evidenced by recent abnormal ABG values,
restlessness, confusion, and recent PVCs.
(2) Ineffective airway clearance related to excessive secretions, as evidenced by yellow, white, thick mucus secretions
that need to be suctioned every hour and diminished/absent breath sounds.
(3) Acute confusion related to sensory overload, sensory deprivation, and sleep pattern disturbance, as evidenced by
agitation and a disordered sleep/wake cycle.
(4) Risk for sepsis infection related to inadequate secondary defenses, use of a corticosteroid, invasive procedures, low
white blood cell count, malnutrition, and chronic diseases.
1. NSG DX #1: Ineffective airway clearance related to excessive secretions, as evidenced by yellow, white, thick mucus
secretions that need to be suctioned every hour and diminished/absent breath sounds.
(a) NURSING ASSESSMENT
a. Related Assessments: sputum, clinical manifestations of pneumonia including breath sounds and fever
b. Related Labs and Tests: cultures, bronchoscopy, thoracentesis, chest x-ray, CT PE, MRI spine
c. Relevant Meds: dexamethasone, filgrastim, ceftazidime, metronidazole, vancomycin hydrochloride
(b) SHORT TERM GOAL: The patient’s mucus production will be thinner and only needed every 2 hours by the
end of the shift.
(c) INTERVENTIONS AND RATIONALES
a. Intervention #1: Reposition the patient every 2 hours.
i. Rationale: This may help secretions mobilize (Urden et al., 2018).
b. Intervention #2: Allow rest periods between suctioning, invasive procedures, daily care, and positioning.
i. Rationale: This helps promote energy conservation (Urden et al., 2018).
c. Intervention #3: Help the RT with ETT suctioning.
i. Rationale: This will help remove secretions (Urden et al., 2018).
(d) LONG TERM GOAL: The patient will have a respiratory rate, rhythm, and depth closer to his baseline once
he is off of the ventilator, before discharge.
(e) INTERVENTIONS AND RATIONALES
a. Intervention #1: Give scheduled antibiotics, and assure that when the cultures get back, the organisms are
susceptible.
i. Rationale: This will treat the pneumonia and pleural effusion (Urden et al., 2018).
COMPREHENSIVE NURSING CARE PLAN 17
(f) EVALUATIONS
a. Short term goal: Goal not met, the patient still had copious secretions suctioned every hour.
b. Long term goal: Goal expected to be met, because medication and physical assistance are being
implemented to help the patient clear his infection, and hopefully reliance on the ventilator.
2. NSG DX #2: Risk for sepsis infection related to inadequate secondary defenses, use of a corticosteroid, invasive
procedures, low white blood cell count, malnutrition, and chronic diseases.
(a) NURSING ASSESSMENT
a. Related Assessments: temperature, wound assessments, urine output/stasis, breath sounds
b. Related Labs and Tests: CBC, lactate, cultures
c. Relevant Meds: dexamethasone, filgrastim, ceftazidime, metronidazole, vancomycin hydrochloride
(b) SHORT TERM GOAL: The patient will have a stable temperature, under 100.4 degrees Fahrenheit.
(c) INTERVENTIONS AND RATIONALES
a. Intervention #1: Perform proper hand hygiene and adhere to contact precautions.
i. Rationale: This reduces the transmission of microorganisms (Urden et al., 2018).
b. Intervention #2: Collaborate with physician and dietitian to re-implement nutrition, since the patient’s
procedure that did required an NPO order is no longer scheduled for today.
i. Rationale: Nutrition should be adequate for the patient’s body and condition requirements and is
needed to prevent higher susceptibility to infection (Urden et al., 2018).
c. Intervention #3: Maintain caps on all stopcock ports and use aseptic technique when accessing lines.
i. Rationale: This helps reduce portals of entry for new pathogens (Urden et al., 2018).
(d) LONG TERM GOAL: The patient will have improved white blood cell count beyond the current level of 0.6
by time of discharge.
(e) INTERVENTIONS AND RATIONALES
a. Intervention #1: Collaborate with physician and remove ART line and CV line as soon as possible.
i. Rationale: This decreases portals of entry for new pathogens (Urden et al. 2018).
b. Intervention #2: Maintain the head of bed at 30 – 45 degrees.
i. Rationale: This helps decrease the chance of aspiration and further pneumonia infection (Urden et
al. 2018).
c. Intervention #3: Keep urinary drainage tubing and bag below the patient’s bladder level.
i. Rationale: This decreases the incidence of urinary tract infections (Urden et al. 2018).
(f) EVALUATIONS
a. Short term goal: The patient’s goal was met; the highest the patient’s temperature reached was 99.4.
b. Long term goal: Goal expected to be met, because the collaborative care and pathogen combative measures
should help improve the chance for white blood cell production and for reduction of current infections.
What is the worst possible/most likely complication to anticipate based on the primary problem?
The patient could go into septic shock, based on complications that have developed from the primary problem (Urden et
al., 2018).
COMPREHENSIVE NURSING CARE PLAN 18
I will monitor the patient’s temperature, respiratory rate, blood pressure, heart rate, wounds, output, nutrition status,
I will activate a code sepsis. I will draw labs and repeat blood cultures and get an order from the physician. I will
continue to give IV fluids and get an order to give a blous of 500 mL over 30 minutes. I will continue to give vasopressors and
1. Has the status or your patient improved or not as expected to this point?
No, the patient’s condition has not improved. His vitals are stable, but they are getting to a level that is
close to sepsis. The patient still has the need for mechanical ventilation and all invasive lines. He still has a large
2. Do your nursing plans/goals and interventions need to be modified in any way after this evaluation assessment?
Explain:
No, I will continue to implement the same goals and interventions. The patient’s chronic and acute
conditions are compounding each other. Respiratory status, infection, adequate sedation, pain management, and
comfort can be ensured with the goals and interventions that I have been implementing.
3. What will be the most important discharge/education priorities you will reinforce with their medical condition to
prevent future readmission with the same problem? Explain:
Do not smoke, take all of your medications, be mobile, and actively cough and deep breath to prevent
further lung complications. Also, enjoy your family and find reason for motivation.
COMPREHENSIVE NURSING CARE PLAN 19
References
Ackley, B.J, Ladwig, G.B, Flynn Makic, M.B. (2017). Nursing diagnosis handbook: An evidence-based guide to
Malarkey, L. M., McMorrow, M. E. (2012). Saunders nursing guide to laboratory and diagnostic tests (2nd ed.). St.
Shields, K.M., Fox, K.M., & Liebrecht C. (2018). Pearson Nurse’s Drug Guide. Hoboken, NJ: Pearson Education,
Inc.
Urden, L. D., Stacy, K. M., Lough, M. E. (2018). Critical care nursing diagnosis and management (8th ed.).