Care Plan

Student: Makenzie Bradley Date: 10/14/19

Course: 430CC Instructor: Professor Jans

Clincial Site: St. Joseph’s Medical Center Client Identifier: K.H. Age: 33

Reason for Admission: The client was admitted for severe hypotension and severe weakness.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

K.H.’s primary medical diagnosis is sepsis. Sepsis can be a life- Observed: Additional Textbook
threatening condition caused by the body’s response to an infection. The Manifestations:
• Change in mental status
body normally releases chemicals into the bloodstream to fight an
infection. Sepsis occurs when the body's response to these chemicals is • Irritable • Patches of
out of balance, triggering changes that can damage multiple organ • High respiratory rate discolored skin
systems. If sepsis progresses to septic shock, blood pressure drops • Increased heart rate • Low platelet count
dramatically and may lead to death. While it can be caused by any type of • Shortness of breath • Abnormal heart
infection, it is most commonly caused by pneumonia, infection of the • Decreased urination functions
digestive system, the kidney, bladder or the bloodstream. As it worsens, • Low body temperture • Fever above 101 F
the patient goes into septic shock and the blood flow to vitals organs • Low blood pressure • Nausea and vomiting
becomes impaired leading to organ failure and tissue death. Risk factors • Extreme weakness/fatigue
include the very young and the very old, a compromised immune system, • Unconsciousness
have diabetes or cirrhosis, are already very sick, often in a hospital • Diarrhea
intensive care unit, have wounds or injuries, have invasive devices or have
(Lewis, Bucher, Heitkemper, & Harding, 2017).
previously received antibiotics or corticosteroids.
(Mayo Clinic, 2018).

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 Assessment Data
Subjective Data: Patient was unable to report subjective data.
VS: T : 95.5 F Labs: Diagnostics:
BP: 133/60 WBC: 72,000 (3.6-11.1 thousand) CT Abdomen and Pelvis w/ Contrast:
HR: 156 (Increased due to patient in sepsis and positive Severe colonic wall thickening edema and mucosal
RR: 32 for clostridum difficile) hyperenhancement large volume free intrabdominal fluid

O2 Sat: 74% simple mask RDW: 20.8% (11.5-14.5%) CT chest without contrast:
8L (Increased due to patient nutrient deficient) 4x3mm left upper lobe noncalcified pulmonary nodule
Lactic acid: 5.2 (0.4-2.2)
(Increased due to patient in sepsis)
Sodium: 129 (135-145)
(Decreased due to patient’s decreased kidney
function as a result of lupus, diarrhea, and
dehydration)
Potassium: 6.2 (3.5-5)
(Increased due to patient’s decreased kidney
function as a result of lupus and dehydration)
CO2: 13 (19-27)
(decreased due to patient’s decreased kidney
function as a result of lupus)
BUN: 33 (8-25)

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(Increased due to patient’s decreased kidney
function as a result of lupus)
Creatinine: 1.92 (.57-1.11)
(Increased due to patient’s decreased kidney
function as a result of lupus)
Protein: 5 (6.4-8.3)
(decreased due to patient with severe
malnutrition)
Albumin: 3 (3.5-5)
(decreased due to patient deficiency in protein
and in sepsis)
Clost difficile GDH and toxins A&B:
+ toxigenic clostridum difficile
(may be caused by patient’s suppressed immune
system related to lupus)
Glucose: 153
(Increased from stress and patient in sepsis)

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Assessment: Orders: 10/14/19
Past Medical History: Systemic lupus erythematosus, pulmonary Do not resuscitate
hypertension
Do not intubate
Assessment:
NPO
Neuro:
Contact isolation- Clostridum Difficile
LOC: Oriented x 1, to self, then disoriented and lethargic
Continuous cardiac monitor
Speech: moaning, absent
Blood glucose monitoring
Pupils: Equal, Round, R size- 5mm, L Size- 5mm
Consult to hospice
Eyes: do not open spontaneously or to verbal commands
Consult to social worker
Affect: Irritable at first, withdrawn
Spiritual care assessment
Resp.
Oxygen Status: Simple mask 8L, O2 sats 74%
Lung sounds: Diminished
Effort: Labored
Cough: None
Cardio/Vascular
Heart rate: 156 BP: 133/66
Heart tones: S1, S2

Pulses: Radial- weak, Pedal- weak

Capillary Refill: >3 seconds, fingers were blue

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Edema: Upper- Absent, Lower- Absent
JVD: Absent
GI
Abdomen: flat
Tenderness- yes
Ostomy present? No
Bowel sounds: hypoactive
Last BM: 10/13/19 (6 times)
consistency- diarrhea
Diet: Type- NPO
Blood Glucose: 153
GU
Status: oliguric
Urine: dark, amber
Pain/Burning/Difficulty voiding- no
Skin
Color: pale
Status: dry, cool
Wounds: Stage II pressure ulcer on coccyx

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MSK
Upper extremity Motor Response: extremely weak
Lower Extremity Motor Response: extremely weak
Mobility: Bedrest
Fall Precautions: Yes
Monitoring Lines/IVs
Peripheral IVs: Location- right antecubital Size- 20 g
Pain: providing comfort care, administering morphine 2mg Q15
minutes (total 10 mg)

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 Medications
ALLERGIES: NKDA
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Milrinone + 5% 20mg IV As often as Increases myocardial Headache, tremor, 1. Monitor heart
Dextrose Q5 minutes contraction (Vallerand ventricular arrythmias, rate and BP
and Sanoski, 2017). skin rash, increased liver continuously during
enzymes, hypokalemia, administration.
thrombocytopenia Slow or discontinue
(Vallerand and Sanoski, if BP drops
2017). excessively.
2. Monitor ECG
continuosly during
infusion (Vallerand
and Sanoski, 2017).
Norepinephrine 8mg IV As often as Increases BP, Increases Anxiety, dizziness, 1. Monitor heart
Q minute cardiac output (Vallerand headache, insomnia, rate and BP
and Sanoski, 2017). restlessness, tremor, continuously during
weakness, dyspnea, administration.
arrhythmias, bradycardia, Slow or discontinue
chest pain, hypertension, if BP drops
urine output, renal failure, excessively.
hyperglycemia (Vallerand 2. Monitor ECG
and Sanoski, 2017). continuosly during
infusion (Vallerand
and Sanoski, 2017).
Vasopressin 100 units 100 units IV Continuous Decreased urine output- dizziness, “pounding” 1. Monitor serum
in 250 mL NaCl allows reabsorption of sensation in head, MI, electrolyte
water (Vallerand and angina, chest pain, concentration and
Sanoski, 2017). abdominal cramps, urine specific
belching, diarrhea, gravity throughout
flatulence, heartburn, therapy.
nausea, vomiting,
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 paleness, perioral 2. Monitor for
blanching, sweating, water water intoxication
intoxication (Vallerand (Signs and
and Sanoski, 2017). symptoms of water
intoxication include
confusion,
drowsiness,
headache, weight
gain, difficulty
urinating, seizures,
and coma)
(Vallerand and
Sanoski, 2017).
Vancomycin 1000mg IV Once Bactericidal action against Ototoxicity, hypotension, 1.Assess patient for
susceptible organisms- nausea, vomiting, rashes, infection (vital
sepsis (Vallerand and phlebitis, hypersensitivity signs; appearance
Sanoski, 2017). reactions, including of wound; WBC) at
anaphylaxis (Vallerand beginning of and
and Sanoski, 2017). during therapy.
2. Monitor IV site
closely,
vancomycin is
irritating to tissues
and causes necrosis
and severe pain
with extravasation
(Vallerand and
Sanoski, 2017).
Sodium Zirconium 10gm PO Daily Treats hyperkalemia- Mild to moderate swelling 1. Assess potassium
Cyclosilicate lowers potassium level (edema), decreased urine, level before
(Vallerand and Sanoski, dry mouth, increased administration.
2017). thirst, irregular heartbeat,
loss of appetite, mood
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 changes, muscle pain or
cramps, nausea, vomiting
(Vallerand and Sanoski,
2017).
Docusate (Colace) 100 mg Oral PRN- For prevention of Mild cramps, diarrhea,
constipation constipation rashes (Vallerand and
(Vallerand and Sanoski, Sanoski, 2017).
2017).
Furosemide 40mg PO Daily Hypertension-decreases blurred vision, dizziness,
BP (Vallerand and headache, vertigo, hearing
Sanoski, 2017). loss, tinnitus, anorexia,
constipation, diarrhea, dry
mouth, increased BUN,
hyperglycemia,
dehydration,
hyponatremia,
hypovolemia,
hypocalcemia (Vallerand
and Sanoski, 2017).
2. Elevate patients
legs to reduce
edema
(Vallerand and
Sanoski, 2017).
1. Administer with
a glass of water or
juice, may be
adminstered with
an empty stomach
for more rapid
results.
2. Do not
administer within 2
hours of other
laxatives. May
caused increased
absorption.
(Vallerand and
Sanoski, 2017).
1. Monitor
electrolytes,
renaland hepatic
function, serum
glucose, and uric
acid levels before
and periodically
throughout therapy.
2. Instruct patient
to move slowly to
avoid orthostatic
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 hypotension and
dizziness.

(Vallerand and
Sanoski, 2017).

Lorazepam 0.5-2 mg IVP PRN- Decreases anxiety Dizziness, drowsiness,
anxiety (Vallerand and Sanoski, lethargy, headache,
2017). confusion, respiratory
depression, apnia,
bradycardia, nausea,
vomiting (Vallerand and
Sanoski, 2017).
Morphine 1-10mg IVP PRN- Decrease severity of pain Confusion, sedation,
moderate (Vallerand and Sanoski, dizziness, dysphoria,
pain 2017). euphoria, floating feeling,
hallucinations, headache
blurred vision, diplopia,
respiratory depression,
hypotension, bradycardia.
constipation, nausea,
vomiting, urinary retention
(Vallerand and Sanoski,
2017).
1. Assess for signs
and symptoms of
decreased anxiety
(decreased
respirations) to
determine
effectiveness
2. Monitor level of
consciousness and
vitals during
therapy
(Vallerand and
Sanoski, 2017).
1. Assess level of
pain before and 15
minutes after
adminstration to
determine
effectiveness.
2. Monitor
respirations and
heart rate during
therapy
(Vallerand and
Sanoski, 2017).

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Acute pain related to end of life status as evidence by patient appearing irritated and agitated (increased respirations, increased heart rate)
This was chosen as the primary nursing diagnosis because the patient is at the end of her life and providing comfort care is the top priority.
Relieve the patient’s pain Patient does not show 1. Monitor for possibility of 1. Although causes of 1. Goal met. Patient’s
signs of aggitation from changes in mental status, deterioration are numerous aggitation and irritation
(Phelps, Ralph, & Taylor, pain and is comfortable agitation, confusion, in terminal stages, early declined after pain
2017). and in peace by death. restlessness. recognition and medication was
(Phelps, Ralph, & Taylor, 2. Establish pain management of the adminsitered.
2017). management plan with psychological component 2. Goal met. Patient’s
patient, family, and is an integral part of pain pain was managed and
healthcare provider, management. she died peacefully.
including options for 2. Inadequate pain 3. Goal met. The nurse
management of management remains one adminstered the pain
breakthrough pain of the most significant medication on a set
3. Schedule and administer deficiencies in the care of schedule to provide
analgesics as indicated to the dying patient. A plan adequate pain relief and
maximal dosage. Notify developed in advance promote comfort.
physician if regimen is increases patient’s level of (Phelps, Ralph, &
trust that comfort will be Taylor, 2017).

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 inadequate to meet pain
control goal.
(Phelps, Ralph, & Taylor,
2017).
maintained, reducing
anxiety.
3. Helps maintain
“acceptable” level of pain.
Modifications of drug
dosage or combinations
may be required.
(Phelps, Ralph, & Taylor,
2017).

Secondary Nursing Diagnosis: Anticipatory grieving related to expected death of their famliy member as evidence by choked feelings and
denial of loss.
Identify and express Verbalize understanding 1. Provide open, 1. Promotes and 1. Goal met. Patient’s
feelings appropriately. of the stages of grief and nonjudgmental encourages realistic family was provided with
(Phelps, Ralph, & Taylor, loss, express conflicts and environment. Use dialogue about feelings a nonjudgemental
2017). feelings related to family therapeutic and concerns. environment and people to
member’s death before communication skills of 2. Patient may feel talk and comfort them.
leaving the hospital. active listening and supported in expression of 2. Goal met. Patient’s
(Phelps, Ralph, & Taylor, affirmation. feelings by the family members were
2017). 2. Encourage understanding that deep given time to express their
verbalization of thoughts and often conflicting feelings.
and/or concerns and accept emotions are normal and 3. Goal met. Patient’s
expressions of sadness, experienced by others in family’s spiritual needs
anger, rejection. this difficult situation. were met by a spiritual
Acknowledge normality of 3. Providing for spiritual advisor provided.
these feelings. needs, forgiveness, prayer, (Phelps, Ralph, & Taylor,
3. Determine spiritual devotional materials as 2017).
needs and refer to requested can relieve
appropriate team members spiritual pain and provide
including clergy and/or a sense of peace.
spiritual advisor.

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 (Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,
2017). 2017).

Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

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 References

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. M. (2017). Medical surgical nursing (10th ed.). St. Louis, Missouri:

Elsevier.

Mayo Clinic. (2018, November 16). Sepsis. Retrieved 2019, from https://www.mayoclinic.org/diseases-conditions/sepsis/symptoms-

causes/syc-20351214.

Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Nursing diagnosis reference manual (10th ed.). Philadelphia, PA: Wolters Kluwer.

Vallerand, A. H., & Sanoski, C. A. (2017). Davis's drug guide for nurses (fifteenth ed.). Philadelphia, PA: F.A. Davis Company.

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