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Nursing Care Plan

Intensive Care Unit: Learning Contracts To Assess Clinical Practice

(First semester)

Mumtaz Muhammad

DICCN-19-005

Tutor: Muhammad Shahid Riaz

Nursing Division-Begum Mir Nursing Faculty

Shaukat Khanum Memorial Cancer Hospital and Research Centre-Lahore

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Nursing Care Plan

Nursing Care Plan: 01

Nursing Assessment:

Subjective Data: no data as on mechanical ventilator support.

Objective Data: A 32 years YOUNG male patient is known case of Multiple Myeloma came in
ICU with Low GCS, fever and altered sensorium. He was electively intubated. Presenting ICU
day is 11th and ventilator day 7th. He is also found for pneumonia, bacteremia, bacterial
meningitis, AKI, pancytopenia, hyponatremia and raised Creatinine. GCS 3/15 sedated with
injection Midazolam @ 2mg/hr and injection Morphine @ 2mg/hr. bilateral pupils are sluggish
reactive to light and 1mm in size. Sclera both eyes are having edema. Hemodynamically is
stable, afebrile and sinus tachycardia, regular rhythm. OGT is in place on blended renal diet
200ml Q3h. abdomen soft, non-tendon, by auscultation having regular bowel sound and also
having regular opening as once in very shift from last three shifts. Foley’s catheter in place,
oliguria, output 0-10ml/hr since admission, dark brown in color. Skin is intact, warm to touch,
healthy and Wheatish in color. Generalized edema and having right mid axilla pustule. He has
CVC on right jugular vein, IVF N/Saline @ 100ml/hr on flow. ART Line left Brachial in place.
Dialysis catheter is in RT femoral. 1 PRBCS Transfusion is done. He is on contact isolation.

CBC: WBC 4.14, RBC 2.21, HGB 6.2, PLT 18, ANC 2

Electrolytes: Sodium 132, Potassium 3.3, Urea Nitrogen 26.82, Creatinine 5.36, GFR 12.45

ABGs: PCO2 42, PO2 77, HCO3 30.5

Blood culture: Gram negative bacilli

Culture-Others cvc tip: Methicillin Resistant Staphylococcus aureus (MRSA)

Nursing Diagnosis: Risk for Infection Transmission related to Contact transmission exposure as
evidence by Methicillin Resistant Staphylococcus aureus (MRSA) in the culture of CVC tip.

Goals:

Patient and his family members will be know about the using of personal protective equipment
with 1-2 hours.

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Nursing Care Plan

Infection will not be transmitted from patient to other patients, health care workers and to family
members of patient.

Interventions:

Actions Rationales
 Gaudliness of Contact Isolation has  To prevent infection spreading
taken and kept in a separate room. according to the hospital policy

 Contact Isolation Tag placed on door of  easily identification for new comers
patient's room.
 to save the environment and health care
 All required PPEs placed in isolation
provider from harming
trolley in front of patient's room.

 to prevent contamination of the


 Followed facility policy, Dispose of
environment
personal protectives, clothing,
 Monitored temperature, Assess wound
 To notify further infection and to kept
site and dressing changes on the central
the patient in clean and comfort
lines, tubes and catheter.
environment.
 Evaluate all abnormal laboratory
 To conform the isolation cause and
findings, especially culture/sensitivities
type
and complete blood count.
 Maintained aseptic technique for
 To limitation of infection to their point
attending the patient.

 Instruct the patient to tell all visitors


 To prevent spreading of infection and
and personnel to wash their hands
save the patient as well as other
before approaching. Also explained
peoples.
about the using of PPES Limit visitors
when appropriate.

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Nursing Care Plan

Evaluation:

Goals are achieve as by observing the attendant to Hand washing and disposing of protective
personal equipment items in appropriate containers.

Still the patient is under observation as labs are not review.

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Nursing Care Plan

References:

Berman, Snyder, Kozier & Erb (8th Ed) *Kozier & Erb’s Fundamentals of Nursing*
(2003) published by: Prentice Hall New Jersey

Pfaff, S.J., 1980. Nursing care plans for patients in isolation. American journal of infection
control, 8(1), pp.37A-38A.

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