Beruflich Dokumente
Kultur Dokumente
(First semester)
Mumtaz Muhammad
DICCN-19-005
1
Nursing Care Plan
Nursing Assessment:
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
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.
2
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.
3
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.
4
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.