AZUSA PACIFIC UNIVERSITY

SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
COMPREHENSIVE CARE PLAN #: ___1______

Student: Lori Rieser

Instructor: Professor Arlene Naeyaert
Date of Care: 5/20/16
Date of Submission: 6/17/16

Nursing Clinical Worksheet

Student Name: Lori Rieser
Patient Initials: Age:
Sex:
SR
74
F
Allergies
:
PCN
Lisinopri
l
Codeine

Diet:
TPN Q24h
Lipids Q12h

Isolation and
Type:
Contact
Fall Risk:
Braden
Yes
Score:
7

Date: 5/20/16
Admit Date: 4/28/16

Code Status:
Full
Activity:
Strict Bedrest

LOC:
x2
oriented to
place & self

Primary Service: Surgery? Medical?

Medical and Surgical

Admitting Diagnosis: Add Chief complaint ( if presented in ED) Severe sepsis s/t CDiff
ASSESSMENT DATA:
1. History of Present Problem:
74yo F presented with 1wk of worsening diarrhea and weakness, on metronidazole and ciprofloxacin (10 day course for sinus infection), patient
was seen twice in urgent care, admitted the second time.
2. Past Medical History:
Hypertension, Hyperlipidemia, Hysterectomy, Melanoma 2008/2014
What is the relationship of your patients past medical history (PMH) and current medications? Which medications treat which conditions?
PMH
Home Medications
Pharm.
Expected Outcome
Classification
1. Hypertension
1. Low dose aspirin
1. anti-platelet
1. decrease clotting to prevent clotting
2. Hyperlipidemia
2. Statin
2. anti-lipid
2. decrease blood cholesterol to prevent plaque formation
Pt Care begins: Patient is currently intubated (x 2.5wks) in ICU post total colectomy and diverting ileostomy and chest tube (bilateral pleural
effusion)

Doc Flowsheet Data

Vital Signs

0800

Noninvasive Blood
Pressure (NIBP)
Mean Arterial Blood
Pressure (MAP)
Pulse Rate
Respiration Rate (RR)
% O2 Saturation (SpO2)
Temperature

110/40

Hemodynamic Monitoring
Arterial Blood
Pressure (ABP)
Central Venus
Pressure (CVP)
Pulmonary Artery Pressure
(PAP)
Pulmonary Artery
Occlusion Pressure (PAOP)
Cardiac Index
Cardiac Output (CO)

1200
133/69

1600

Ventilator Settings

120/50

64

69

68

110
28
97

100
26
99

0800
N/A

120
41
98
36.8 Q6h
0900
N/A

1000
N/A

1100
N/A

1200
N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A
112 Q6h
9
CPOT
Scale

N/A

N/A

N/A

Mode: PRVC
(Tried to switch to CPAP
@7am lasted hour,
patient not able to tolerate)

4
CPOT
Scale

Intake ( ml per shift)

NS 500ml
Bolus x1/shift

Rate: Set at 14, patient has

spontaneous breaths at 28
TV: 355
FiO2: 40%

N/A

Other
Intracranial Pressure (ICP)
Blood Glucose (POC)
Pain Level

IV Fluids
Type

PEEP: 5
PS: 7.2 minimum

5
CPOT
Scale
Output (ml per shift)

Rate/ Site

Intake/Output
Shift Total

Oral

Enteral

IV

TOTAL

500ml TPN
172.8 Lipids

500ml NS
650ml
Ampho B

1822.8ml

Urine
Outpu
t
1200

BM

Emesis

Drains

TOTAL

Ileostomy
Scant

None

CT 64ml
JP 40ml

1304

Please state why there is a significant difference in the I/O (if any):
Patient is on continuous bladder irrigation with Ampho B antibiotic as well as TPN/Lipids and NS bolus of 500ml on my shift (no continuous fluids at this point) and Patient
is edematous (third spacing); Patient was retaining fluids in tissues; assessment revealed palpable pulses and warm to touch however, fluids are low in main vascular
space. Patient was dcd from Lasix drip 1 day prior to my care.

PLACE ECG STRIP HERE

HR
Rhythm
114
Regular
Interpretation:
Sinus Tachycardia

P wave
0.12

PR
.20

QRS
.04

P:Q ratio

ST segment

T-wave

Q-T

Ectopy

Complete Head-To-Toe Assessment

General
Survey

Neurologic

Pain
Assessment

Physical
Appearance:

Patient is lying in bed, intubated, restrained. She is not sedated but is being treated for pain.

Mood:

Patient appears agitated; anxious in pain

Signs of Acute
Distress:

grimace; hands restrained, but shaking intermittently.

Orientation

patient responds and follows commands

Speech

patient can not speak; she is intubated

Pupil (L)

2mm

Pupil (R)

2mm

GCS score

10

Abnormal
Muscles

Location:

n/a

Strength:
abdomen

n/a

Provocation/
palliation
Quality

Not able to assess; pt nods when asked if abdomen hurts

Region/
Radiation
Severity
Time

Not able to assess; pt nods when asked if abdomen hurts

Oxygenation

Room Air Device

L/min

Respiration

Quality: __slightly labored; patient attempts to breath on her own, but tires easily, attempts at
CPAP this AM were unsuccessful
Rate:
28/ min spontaneous / vent set at 14
Rhythm: spontaneous; but irregular
Diminished

Pulmonary

based on grimace, 6+
Not able to assess
Ventilator

Flow rate: ___Fi02 40%_____

R. Lung
Diminished

Cardiovascular

Gastrointestinal

Genitourinary

Skin
(wounds)

Musculoskeletal

L. Lung
Capillary
Refill
Skin Color/
Temp
Apical Pulse
Heart Sounds
Peripheral
Pulses
Oral Mucosa
Tongue
Abdomen
Nutrition
Tube Feeding
Bowel Sounds
Bowel
Movement
Urination
Urine Color
Urine
Character
Urine (ml)
Urinary
Catheter
Skin Color
Skin Integrity
Wound/
Ostomy
Insertion
Site(s)
IV Assessment
IV Fluids
Describe
abnormalities:

2 sec
warm, dry
Normal sinus rhythm
normal s1, s2 sounds
radial and pedal assessed bilaterally, equal, WNL
Wet, oral care given
Wet, oral care given
extremely tender (not able to palpate) due to 6in midline incision
TPN Q24h and lipids Q12h NS 500ml
Current Rate: __n/a_________ Goal Rate: _____________
Residuals: _____________ Type: N/A
NGT
PEG
hypoactive
Last BM date: ___scant amount in ileostomy_______

J-tube

currently undergoing continuous bladder antibiotic irrigation

Yellow
Clear
1600ml
Insertion date: __4/29________
pink, warm to touch
heels intact, skin intact except sacrum blanchable; edema
midline abdominal 6in incision clean, dry, minimal serous drainage; ileostomy pink, beefy,
scant drainage
Right side chest tube insertion site clean, dry, no drainage; R side PICC & L side JV central
line; no peripheral IVs.
R side PICC line for TPN/Lipids/Fluids, dressing changed 5/19/16, clean, dry, intact, no
drainage; L side JV central line dressing changed 5/18/16, clean, dry, intact, no drainage.
NS 500ml at
OT reported normal ROM as tolerated; assessment revealed ROM WNL

Psychosocial
History

Marital status
Education level
Social resources
Spiritual resources
Occupation
Employment
Smoking
Alcohol
Recreational Drugs

Psychosocial Assessment
Divorced
College
Family
Not able to assess
Retired
Speech Pathologist
No History
No History
No History
Spiritual Assessment

Spiritual
Integrity
Presence
of..
X
X
X
X
X

1)

Look: (Signs of Meaning, Relationships, Hope and Joy)

Provide checkmark in either box for each criteria

Spiritual
Distress
Absence
of.

Family, friends, visitors, wedding ring, photographs

Cards, letters, phone calls, flowers, pets
(by OT) Attention to personal care and appearance
Work, projects, hobbies, music, books, tapes
Newspapers, magazines, television, radio
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 (not able to assess)
Uses the observations listed above to begin your Spiritual Assessment
Acknowledge and inquire about photographs, cards, flowers, visitors X
Acknowledge and inquire about hobbies, books, television/newspaper content (not able to assess)
Acknowledge strength and inquire about profession (not able to assess)
Acknowledge and inquire about articles of faith & religious preference (not able to assess)
Acknowledge and inquire about mood (physical and psychological) (not able to assess)
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 would like to hear more about your life and/or your family.
When you return home, will there be someone available to help you? (min assess; family at bedside;
prognosis unknown)
What brings you joy, makes you happy, or makes you laugh? (not able to assess)
What has brought you the greatest sense of pride and accomplishment to date? (not able to assess)
What is your next goal? (not able to assess)
What give you such strength? (not able to assess)
Who do you turn to in tough times? (not able to assess)
Would you like me to pray for you or with you? (not able to assess)
Listen: (Actively listen for signs of meaning, relationships, hope,
Spiritual Integrity
Spiritual Distress
and joy)
**Provide checkmark in each box that is applicable
Pt verbalizes...
(Patient is intubated/non-verbal; family present but not able to
Pt verbalizes
complete assessment on the items below)
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.
X Potential for Enhanced Spiritual Well-Being (assumed based on current status)
X Spiritual Distress (assumed based on current status/ unknown prognosis)
Hopelessness
Other
3. Plan: Develop a short-term goal and a long term goal for your client.
ST Goal: The Client will be given comfort from nursing staff and family
LT Goal: The Client will feel supported and nurtured despite prognosis outcome
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
X Active listening. (pt non-verbal)
X Assist client to identify strengths, supports, and interconnections. (Family present)
X Instill hope.
X Use of touch, if client is comfortable with closeness.
X Provide an environment conductive to reflection, prayer, and spiritual growth. (done with family)
X Provide an environment conductive to clients beliefs (food, ceremonies.)
- Provide religious articles as requested. (none requested)
X Support client in search for meaning and purpose in life, illness, and death
- Support client in search for a relationship with a higher power. (not able to)
- Pray with the client. (not able to)
X Pray for the client.
X Promote private time with people who are significant in clients life.
X Be available and approachable to assist client with meeting spiritual needs, and making spiritual
choices.
- Collaborate with chaplain or spiritual leader. (not requested/ needed at my shift)
Other:
Other:
5. Evaluation: Evaluate the clients progress towards the goals.
(Note: Each persons spirituality is highly variable, individual, and ever changing!)
ST Goal: Patient given comfort by both staff and family
LT Goal: Patient appeared more calm, less anxious in later half of shift, suggesting that goal is at least partially
met
**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?
Relevant Vital Sign Data:

Clinical Significance:

1. Heart Rate Sinus Tachycardia

1. This indicate signs of pain/distress; and also watching BP increase as

would indicate pain as well; lower BP might indicate hypovolemia or
worsening infection

2. Temperature- Febrile

2. Watching Temp for any recurrent spikes in temperature as she was

febrile overnight; could be signs of worsening infection

3. Respiratory Rate elevated

3. Vent set to 14; pt breaths spontaneously at 28/min, need to watch for
hyperventilation as signs of pain or worsening respiratory function

RELEVANT Assessment Data:

Clinical Significance:

Pain in abdomen

Pt is experiencing worsening pain in abdomen; multiple radiology tests are being done to
determine the cause

Radiology Reports: What diagnostic results are relevant that must be recognized as clinically significant for the nurse?
Relevant Results:

Clinical Significance:

X-ray

Chest xray for bilateral pleural effusion chest tube; results- effusion is improving

CT Scan

Abdominal and pelvis: revealed hepatomegaly and distended gallbladder

MRI/Ultrasound

Abdominal: revealed sludge in gallbladder; no stones

Other: HIDA scan

nuclear study of liver, gallbladder and bile ducts; results pending

Lab Order(s)

Current values:

N/H/L

Previous Results:

If applicable

Complete Blood

Clinical Significance

(No access to

Count

for High or Low

computer record

results / Trends:

for earlier results)

Stable/Improve/worse
WBC

5/20/16 5am: 12.8

High; Improving

5/19/16 5am: 13.2

Hgb

5/20/16 5am: 7.5

Low; Improving

5/19/16 5am: 6.1

Hct

5/20/16 5am: 21.5

Low; Improving

5/19/16 5am: 20.1

Platelets

5/20/16 5am: 10.4

Low; Improving

5/19/16 5am: 10.1

PT

5/20/16 5am: 10.4

Low; Improving

5/19/16 5am: 9.8

INR

5/20/16 5am: 1.0

Stable; Improving

5/19/16 5am: 1.0

PTT

5/20/16 5am: 38

Stable; Improving

5/19/16 5am: 37

Basic Metabolic
Panel
Sodium

5/20/16 5am: 134

High; Abnormal;

5/19/16 5am: 135

Improving
Potassium

5/20/16 5am: 3.4

High end of normal;

5/19/16 5am: 3.5

Improving
Glucose

5/20/16 5am: 112

High end of normal;

5/19/16 5am: 126

Improving
BUN

5/20/16 5am: 17

Stable; Improving

5/19/16 5am: 17

Creatinine

5/20/16 5am: 0.45

Stable; Improving

5/19/16 5am: 0.45

Calcium

5/20/16 5am: 1.16

Stable; Improving

5/19/16 5am: 1.15

Chloride

5/20/16 5am: 96

Stable; Improving

5/19/16 5am: 96

Bicarb

5/20/16 5am: 30

Improving

5/19/16 5am: 32

Mag

5/20/16 5am: 2.0

Stable

5/19/16 5am: 2.0

Phos

5/20/16 5am: 3.9

Stable

5/19/16 5am: 3.8

GFR

5/20/16 5am: >60

Stable

5/19/16 5am: >60

Lactate

5/20/16 5am: 1.0

Stable

5/19/16 5am: 1.0

5/20/16 5am:

WNL; current trend is

(Day of Colectomy

5/5/16 Positive:

improving

Surgery)

Escherichia coli,

Other Labs:
Blood Culture

culture taken; results

pending

5/15/15: Negative

4/28/16: Negative

Enterococcus
fecalis Clostridium
Difficile

Urine Culture

5/20/16 5am:
culture taken; results

Abnormal; current

5/5/16 Positive: VRE

trend is stable

5/5/16 Positive:

4/28/16: Positive: VRE

VRE

pending
Sputum Culture

5/20/16 5am:
culture taken; results
pending

Fecal

5/20/16 5am:
culture taken; results

Abnormal; current

5/5/16 Positive:

5/5/16 Positive:

trend worsened d/t

Klebessla pneumonia

Klebessla

intubation; now is

4/28/26: Negative

pneumonia

stable
Abnormal; current

5/5/16: Positive:

5/5/16: Positive:

4/28/16 Positive:

trend is stable

Clostridium Difficile

Clostridium Difficile

Clostridium Difficile

pending

What lab results are relevant that must be recognized as clinically significant to the nurse?

Relevant Labs:

Clinical Significance:

Trends: Improve/worsening/Stable

WBC

to monitor the bodys response

Still high, but the trend is improving

to multiple systemic infections

H&H

to monitor the bodys ability to

Still low, but the trend is improving after pt received

produce RBCs and oxygenate

PRBC therapy overnight (prior shift)

body
BUN,

To ensure kidneys are working

Creatinine

sufficiently due to multiple

Stable and improving

systemic infections; also

vancomycin and amphotericin
B are nephrotoxic
Cultures

To ensure infections are

Blood culture is improving with latest test revealing

(blood,

clearing or improving

normal. All others are still abnormal; and are stable.

to monitor for metabolic

Current result is stable.

sputum, urine,
fecal)
Lactate

acidosis
Current Medications List: Create a list of medications that you administered during your shift: (Reference Needed)

Scheduled Medications and PRN Medication Given

(please also include all saline flushes and IVFs)
Generic Name : Amphotericin B
Classification : antifungal / Polyene

Dose: 42

Trade Name : Amphocin and Fungizone

Route:
Frequency/ Rate: continuous

bladder
Pt. Specific Indications: infection in bladder causing UTI and AKI
Mechanism of Action: Amphotericin B binds fungal cell membranes causing subsequent fungal
cell death
Contraindications: white blood cell (leukocyte) transfusions, heart disease (e.g., irregular
heartbeat, congestive heart failure), liver disease, kidney disease.
Side Effects: hypotension, anorexia, nausea,
Adverse Effects: hypokalemia,
vomiting, headache, dyspnea and tachypnea,
hypomagnesemia, hepatoxicity, leukopenia,
drowsiness, and generalized weakness
thrombopenia, serious cardiac arrhythmias
(including ventricular fibrillation), cardiac
failure
Patient Family Education: report side effects,
Generic Name : Fentanyl Citrate
Trade Name : Fentenil, Actiq
Classification : Narcotic; opioid
Dose:
Route: IV
Frequency/ Rate: prn
analgesic
150mg
breakthrough pain
Pt. Specific Indications: severe breakthrough pain
Mechanism of Action: Inhibits Acceding Pain Pathways In CNS; mu-opioid receptor agonist
Contraindications: known intolerance or hypersensitivity to any of its components or the drug
fentanyl and Anaphylaxis
Side Effects: dry mouth, headache, dizziness,
Adverse Effects: weak or shallow breathing,
weakness, anxiety, nausea, vomiting, or
slow heart rate;
constipation.
extreme sleepiness; or dizziness, loss of
consciousness.
Patient Family Education: risk of dependence; report side effects

Trade Name : Hydromorphone

Generic Name : Dilaudid
Classification : Opiate Analgesic
Dose: 2mg Route: IV
Frequency/ Rate: 2mg/hr
Pt. Specific Indications: Severe pain from post-op total colectomy
Mechanism of Action: Inhibits Acceding Pain Pathways In CNS
Contraindications: known hypersensitivity to hydromorphone, patients with respiratory depression in the
absence of resuscitative equipment, and in patients with status asthmaticus
Side Effects: Drowsiness, Dizziness, Confusion,
Adverse Effects: Respiratory
constipation, lowered respiratory rate
Depression/Arrest, Seizures
Patient Family Education: Teach To Report CNS Changes, Teach Physical Dependency Is Risk
Generic Name : Vancomycin HCL
Classification : Anti-biotic /
Dose:
TRICYLIC GLYCOPEPTIDE
1.5mg/Sodium

Trade Name :
Route: IV

Frequency/ Rate: Q12h

Chloride 250ml
Pt. Specific Indications: Multiple systemic infections: Blood, sputum and fecal infections
Mechanism of Action: INHIBITS BACTERIAL CELL WALL SYNTHESIS; BLOCKS GLYCOPEPTIDES
Contraindications: hypersensitivity to this antibiotic. Solutions containing dextrose may be
contraindicated in patients with known allergy to corn or corn products; particular care given for
patients with kidney and liver disease
Side Effects: HEADACHE, HYPOTENSION,
Adverse Effects: CARDIAC ARREST, VASCULAR
PERIPHERAL EDEMA, OTOTOXICITY, TINNITUS,
COLLAPSE, NAUSEA, MEMBRANE COLLITIS,
PERMANENT DEAFNESS, CHILLS, FEVER, RASH,
NEPHROTOXCITY, FATAL UREMIA, LEUKOPENIA,
THROMOBILITIES AT IV SITE, BACK PAIN,
ESINOPHILLA, ANAPHALAXIS, SUPERINFECTION
WHEEZING, DYSPNEA
Patient Family Education: TEACH ABOUT ASPECTS OF PRODUCT THERAPY AND NEED TO
COMPLETE ENTIRE COURSE; TEACH TO REPORT SORE THROAT, FEVER, FATIGUE AS THIS COULD
INDICATE SUPER INFECTION

Below are PRN medications not given

Trade Name : Furosimide
Generic Name : Lasix
Classification : loop diuretic
Route: IV
Frequency/ Rate: PRN
Dose: 40mg
Pt. Specific Indications: third spacing edema
Mechanism of Action: INHIBITS REABSORPTION OF SODIUM AND CHLORIDE AT PROXIMAL AND
DISTAL TUBULE AND IN THE LOOP OF HENLE
Contraindications: anuria and in patients with a history of hypersensitivity to furosemide.
Side Effects: HEADACHE, FATIGUE, WEAKNESS,
Adverse Effects: CIRCULATORY COLLAPSE.
VERTIGO, ORTHOSTATIC HYPOTENSION, CHEST
RENAL FAILURE, THROBOCYPENIA,
PAIN, ECG CHANGES, HYPOKALEMIA,
AGRANLUCYTOMSIS, LUEKOPNEIA, ANEMIA,
HYPOCHLOREMIC, ALKALOSIS, HYPERURICEMIA,
STEVENS-JOHNSON SYNDROME, TONIX
HYPOCALCEMIA, HYPONATRIMIA, METABOLIC
EPIDERMAL NECROLOYSIS.
AKLALOSIS, HYPERGLYCIMIA, NAUSEA,
VOMITTING
Patient Family Education: TEACH PATIENT TO CHANGE POSITIONS SLOWLY TO PREVENT
ORTHOSTATIC HYPOTENSION, TEACH PATIENT TO RECOGNIZE ADVERSE EVENTS LIKE MUSCLE
RAMPS, WEAKNESS, NAUSEA, DIZZINESS
Trade Name :
Generic Name : Levophed
Classification : vasopressor
Dose:
Route: IV
Frequency/ Rate: PRN;
titrate down
4mg/1000ml
Pt. Specific Indications: Multiple systemic infections: Blood, sputum and fecal infections
Mechanism of Action: peripheral vasoconstrictor (alpha-adrenergic action) and as an inotropic
stimulator of the heart and dilator of coronary arteries (beta-adrenergic action)
Contraindications: hypotensive from blood volume deficits except as an emergency measure to
maintain coronary and cerebral artery perfusion until blood volume replacement therapy can be

completed
Side Effects: HEADACHE, HYPOTENSION,
PERIPHERAL EDEMA, OTOTOXICITY, TINNITUS,
PERMANENT DEAFNESS, CHILLS, FEVER, RASH,
THROMOBILITIES AT IV SITE, BACK PAIN,
WHEEZING, DYSPNEA

Adverse Effects: pain, burning, irritation,

discoloration, or skin changes where the
injection is given; sudden numbness,
weakness, or cold feeling anywhere in your
body;
slow or uneven heart rate; cyanosis, mottled
skin; oliguria
Patient Family Education: TEACH ABOUT ASPECTS OF PRODUCT THERAPY AND NEED TO
COMPLETE ENTIRE COURSE; TEACH TO REPORT SORE THROAT, FEVER, FATIGUE AS THIS COULD
INDICATE SUPER INFECTION

List 4 Nursing Diagnoses In Order Of Highest Priority:

(Based on your patients specific needs, identify three nursing diagnosis and rank them in
order of importance,
be sure to include at least one physiologic and one psychosocial diagnosis)
1). Risk for Infection (progression from sepsis to septic shock) related to the development of
opportunistic infections.
2) Altered tissue perfusion related to vasodilation, increased capillary permeability, in response
inflammatory mediators that are released in a serious infection; rapid respirations and
progression of septic shock.
3) Ineffective breathing pattern related to rapid respirations and progression of septic shock.
4) Anxiety related to feelings that illness is worsening and is potentially life threatening,

Select one physiologic and one psychosocial nursing diagnosis listed above and create a
nursing care plan for each selection:
(For each nursing diagnosis provide 1 goal, 3 interventions with rationales, and indicate if goal was met, not met or
in progress)

List of Real/ Potential Nursing

NSG DX #2

NSG DX #1

Risk for Infection

(progression from
sepsis to septic shock)
related to the
development of
opportunistic
infections.

1). Risk for Infection (progression from sepsis

to septic shock) related to the development of
opportunistic infections.
2) (Altered) ineffective tissue perfusion related
to vasodilation, increased capillary permeability, in
response inflammatory mediators that are
released in a serious infection; rapid respirations
and progression of septic shock
3) Ineffective breathing pattern related to the
reduced supply of oxygen / breathing irregular.
4) Anxiety related to feelings that illness is
worsening and is potentially life threatening,

Ineffective tissue
perfusion related to
the reduced supply of
oxygen / breathing
irregular.

Outcome Parameters

Related Assessment

NSG DX #1: risk for worsening infection

Patient has been febrile overnight
(progression from sepsis to septic shock) related to
the development of opportunistic infections.
infection is recognized
And is currently WNL
immediately to prevent

Worsening
and treated

Interventions & Rationales

1)

Assess temperature and vital signs Q1h

Patient has + cultures in urine,

(and the septic cascade
Rationale: high fever, chills indicate worsening
fecal, and sputum for multiple
death)

septic shock

condition, Alerted LOC, elevated HR and lower BP

can be signs of shock.

into MODS, DIC,

organisms.
2) Monitor daily WBC & cultures; take new samples if
afebrile and daily
fever develops
continue to improve or remain
Rationale: an increasing WBC indicates immune
stable.
system is not combating infection effectively; +
cultures mean infection is present
3) Administer medications as prescribed
Rationale: Vancomycin and Amphotericin will
help to fight the multiple infections to keep them
from spreading or getting worse

Patient remains
labs
Evaluation

Patients condition of
sepsis will continue to
improve

patients lab work will

improve before leaving
ICU

Patient will not have

any spread of infection or
worsening infection

Relevant Labs and Tests

Blood, sputum, fecal, and urine cultures reveal + infection for
Elevated WBC
Decreased H&H

Relevant Meds

Vancomycin
Amphotericin
Outcome Parameters

Related Assessment

Interventions & Rationales

NSG DX # 2:
1)
Assess respiratory rate, depth, effort, observation
Patient respirations at 28/min,though
Altered tissue perfusion related to vasodilation,
and report signs and symptoms of respiratory distress
will remain WNL
increased capillary permeability, in response
inflammatory mediators that are released in a
Rationale:
increase
respiratory
effort
she is intubated and set at 14/min
serious infection;
rapid
respirations
andcould
progression
indicate
worsening
septic
condition
and
Altered LOC
advancement to shock

Vital signs
No

Patient has bilateral pleural effusion

signs of
2) Assess for and report signs of diminished tissue
decreased cardiac output

perfusion (decreased blood pressure, altered LOC, cool

making deep respiration moreextremities,
difficult pallor or cyanosis, diminished or absent
peripheral pulses, slow capillary refill, edema,
oliguria).
Rationale: provides information about the degree
/ adequacy of tissue perfusion and help determine
the need for intervention.
3) Monitor BP and vital signs; administer vasopressors
as ordered.
Rationale: When BP is low, cardiac output can be
effected and vasopressors will regulate BP.

absence of

Evaluation

Patient will continue to

maintain BP WNL and not
need vasopressors

Patient will improve

respiratory rate

Patient will not show

signs of worsening tissue
perfusion

Relevant Meds
Relevant Labs and Tests
Decreased H&H
On ventilator, and not tolerating attempts to lessen sup
Fi02 at 40%

Levophed
Lasix
Vancomycin/ Amphotericin

1. What is the worst possible/most likely complication to anticipate based on the primary problem?
Death from the sepsis cascade very possible at this point. Patient is showing signs of septic
shock and beginning MODS (multi organ failure). Patients prognosis is unknown.
2. What nursing assessments will identify this complication EARLY if it develops?
Temperature, Cultures (Blood, sputum, urine) Heart rate, B/P, H&H, CBC,
3. What nursing interventions will you initiate if this complication develops?
Immediately inform MD of change and administer medications / orders as prescribed
EVALUATION:
All physicians orders have been implemented that are listed under medical management. Evaluate the
response of your patient to nursing and medical interventions during your shift.
1. Has the status or your patient improved or not as expected to this point?
The patient has improved somewhat since her total colectomy; however, the patient is still in critical
condition. The patient has developed multiple infections in sputum and urine as well as blood and fecal.
The blood culture came back normal today; but the sputum, urine, and fecal are still positive. The
patients A-line was removed yesterday (before my shift) and is considered hemodynamically stable for
the moment. The plan is to extubate the patient as soon as possible because shes been intubate for 2.5
weeks and risks having a trach if not extubated soon. The patient is considered stable in critical
condition.
2. Do your nursing plans/goals and interventions need to be modified in any way after
this evaluation assessment? Explain:
No, the most risk of mortality to the patient is the risk of infection (progression of sepsis to septic shock)
and multiple organ failure. Assessing her vital signs and labs frequently will help to catch any worsening
of her condition and treat it quickly. The next thing is her altered tissue perfusion due to her bodys
inflammatory response to her severe sepsis. This is causing fluid shifts, third spacing, and although she
is currently hemodynamically stable, she need to be monitored closely for any worsening signs. This is
also a risk for mortality for this patient.
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:
The patient faces a long recovery, even if she continues to improve and is transferred out of the ICU. At
this point, her condition is critical and it would be hard to assess education she would need if she is
discharged because that is a long way off from this point. However, I would emphasize good nutrition for
healing and closely adhering to the treatment plan including medications and rehabilitation. I suspect that
if this patient does get better and is transferred to a step-down unit, she would be discharged to a
rehabilitation hospital first before going home due to the severity of her illness.

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Bedside shift report

It is now the end of your shift. Effective and concise handoffs are essential to excellent care and if not
done well can adversely impact the care of this patient. You have done an excellent job at this point, now
finish strong and provide report to the nurse who will be caring for this patient after you. Include the
patient and family, as they are the center of care .
S- 94 yo female presented to urgent care with worsening diarrhea, fever and weakness over prior week
and was admitted with severe sepsis secondary to C.Diff to 3west on 4/29, intubated and transferred to
ICU 5/2.
B- HX: HTN, Hyperlipidemia, melanoma, hysterectomy; Since hospitalization, patient has had 2 fecal
implantations and bowel cleaning with vancomycin, all unsuccessful resulting in total colectomy and
ileostomy 5/17. Patient developed other infections in urine and sputum 5/15. Patient is on TPN & lipids,
NS bolus PRN, Dilaudid drip, Fentanyl PRN for breakthrough pain, Vancomycin Q12h, and Amphotericin
continuous bladder irrigation. Lasix and Levophed were discontinued, but are on hand as PRN.
A- Patient was febrile and tachycardic overnight, on my shift, abrile,but still tachy. Breakthrough pain is
major concern at the moment. Her team of Drs are trying to rule out peritonitis and/or cholecystisis. She
has received xray, ultrasound, MRI and HIDA scan today, so far no definitive results. Patient also had
two attempts to ween intubation from PVRC to CPAP and she could not tolerate it for more than 30mins.
She is currently on PVRC, Fi02 40%, TV 400, peep 5. Drs are holding further weening until the
abdominal issue is clear.
R- Continue to monitor patient for signs of worsening infection and monitor pain level.
Open the medical record or access the electronic work-station in the patients room.
- Conduct a verbal report with the patient and family. Use words that the patient and family can
understand
- Why is the patient here ?- reason for admission
The patient is here for severe sepsis; that means that the patient has a serious infection in her blood.
She also has other infections in her body including in her urine, feces, and sputum; or lungs.
- What is the current status? - is the patient meeting the length of stay goals/major benchmarks for this
diagnosis
The patient is currently stable, in critical condition. The patients condition has improved somewhat since
her admission 3.5 weeks ago. She has undergone many procedures to help treat her severe sepsis.
- What is the plan for discharge?
At this point, the patient is expected to remain in the ICU until she can be extubated. That means that the
patient is currently on a machine to help her breath, and when she no longer needs that machine, she
may be eligible to be transferred to a less critical care unit.
- Identify the patients and familys needs or concerns.
The patient and familys immediate concerns is whether or not the patient will die.
- Ask the patient and family:

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17

o What could have gone better during the last 12 hours? Not able to assess.
o Tell us how your pain is. Not able to assess.
o Tell us how much you walked today. Not able to assess.
o Do you have any concerns about safety? Not able to assess.
o Do you have any worries you would like to share? Not able to assess.
- Ask the patient and family what the goal is for the next shift. This is the patients goal not the nursing
staffs goal for the patient.
Not able to assess; although I assume it would be foremost to keep the patient alive.
o What do you want to happen during the next 12 hours?
Not able to assess.

References:
Ackley, B.J., & Ladwig, G.B. (2014). Nursing diagnosis handbook: An evidence-based guide to Planning
care. Maryland Heights, MO: Mosby Elsevier.
Baird, M.S. (2016). Manual of Critical Care Nursing (7th ed.). St. Louis: Elsevier.
Malarkey, L.M., & McMorrow, M.E. (2012). Saunders Nursing guide to laboratory and diagnostic tests. St.
Louis, MO: Elsevier
Skidmore-Roth, L. (2015). Mosbys 2015 nursing drug reference. Littleton, CO: Elsevier Mosby Inc.
Urden, L.D., Stacy, K. M., Lough, & M. E., (2014). Critical Care Nursing: Diagnosis and Management, (7th
Ed.) St. Louis: Elsevier.

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