SAULT COLLEGE OF APPLIED ARTS AND TECHNOLOGY

Care Plan by JOIDA MAE ESPER I. CANONO IEN-ENP

Code Status: FULL CODE VS: BP- 114/76 , HR- 69 , RR- 20 , T-36.6 , O2sat-97% Wt: 101.2 kg
Admitting DX : Diet: REGULAR IV: G.24 LT HAND LBM: 02-10-23 BG: 5.7
ER: SEP. 9,22 Medical (3A): NOV. 30,22 ICU: DEC. 2,22 Medical: DEC. 25, 22 Rehab: JAN. 27, 23 Oxygen: Room Air O2 Sat: 97% Tubes: IFC in situ (INSERTED 31/1/23)
Allergies: PIPTAZ, VANCOMYCIN Wound: EXCORIATION AT COCCYX Dressing: ADAPTIC POWDER/CALMOSEPTINE Isolation: CONTACT
Surgical Intervention: CIRCUMCISSION & CHORDEE REPAIR; OPEN TRANSVESICAL CYSTOLITH OTOMY Activity: Level A Lift/Transfer: N/A Level of Risk for Falls: HIGH Braden: AT RISK
Anesthesia: GENERAL Other: with Hearing and visual impairment.
Coexisting Illness(es): Bladder calculi, BPH, Remote renal lithiasis, Vertigo, Tonsillectomy

ASSESSMENT PLANNING
Behaviour/Responses/Findings Nursing Interventions EVALUATION
(Data collection information and
Nursing Diagnosis AMB/AEB Goal
(including time frame)
observations)

Risk for Septic Shock As manisfested by Client will display -Monitor trends in blood pressure After implementation of the
Subjective: related to infection or delirium and evidenced by adequate perfusion (BP), especially noting progressive interventions, the
Urosepsis leukocytosis and elevated as evidenced by hypotension and widening pulse Patient displayed
-PMHx of bladder calculi, BPH, BUN and creatinine. stable vital signs, pressure. (Hypotension develops as hemodynamic stability.
remote renal lithiasis, chronic UTI circulating microorganisms stimulate
palpable peripheral Patient verbalized
-had PE; post code
pulses, skin warm release and activation of chemical and understanding of the disease
-had Atrial flutter and Afib
-on Apixaban 5 mg and dry, usual level hormonal substances. These process.
-allergy to Piptaz and Vancomycin of mentation, endotoxins initially cause peripheral
individually vasodilation, decreased systemic
appropriate urinary vascular resistance (SVR), and relative
Objective: output, and active hypovolemia. As shock progress, the
bowel sounds. cardiac output becomes severely
-Pt’s weight- 101.2 kg. depressed due to major alterations in
-with IFC since admission contractility, preload, and/or
-delirium noted afterload, thus producing profound
-excoriations on coccyx hypotension.)

-Labs: WBC 12.4 RBC 3.76, Hgb 107,
Hct 0.339, K 4.3, Cl 108, BUN 7.5,
Creatinine 125, eGFR 49.
V/s: BP- 114/76 , HR- 69 , RR- 20 , T-
36.6 , O2sat-97% on RA
-Monitor heart rate and rhythm. Note
dysrhythmias.
-Note quality and strength of
peripheral pulses.
-Assess respiratory rate, depth, and
quality. Note onset of severe dyspnea.
-Assess skin for changes in color,
temperature, and moisture.
-Assess for changes in sensorium
(confusion, lethargy, personality
changes, stupor, delirium, and coma).
-Measure hourly urine output; record
urine specific gravity.
-Monitor for signs of bleeding; oozing
from puncture sites or suture lines,
petechiae, ecchymoses, hematuria,
epistaxis, hemoptysis, and
hematemesis.
-Evaluate lower extremities for local
tissue swelling, erythema, and
positive Homan’s sign (calf pain at
dorsiflexion of the foot).
-Maintain stable body temperature,
using adjunctive aids as necessary.
-Provide supplemental oxygen.