CARE PLAN SEPSIS and other medical conditions

CARE PLAN SEPSIS and other medical conditions

CARE PLAN SEPSIS and other medical conditions

Concept Map Student Name: Instructor: Erickson’s Developmental Stage Related to pt.& Cite References (1) History of Present Illness (HPI), Pathophysiology of Admitting Dx (Cite References) Medical, Surgical, Social History (1). Patient Education (In Pt.) & Discharge Planning (home needs) In patient: Acute on chronic systolic and diastolic Congestive Heart Failure (CHF). Home care: Cultural considerations, ethnicity, occupation, religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation & Psychosocial Considerations/Concerns, to include the following Social Determinants of Health Diagnostic Test/ Lab Results with dates and Normal Ranges (3) Test Norms BUN 7-20 mg/dL CREATIN INE 0.5 to 1.1 mg/dL PT 11-12.5 seconds INR 0.761.27 WBC 4.511.0 Hct 37-47% Hbg 12-16 g/100m L PLATELE TS Na K Date 9/15/ 19 9/15/1 9 Current Value 43 1.3 9/15/ 19 9/15/ 19 9/15/1 9 9/15/1 9 9/15/1 9 27.7 H 150 to 400 × 10 9/L 9/15/ 19 114 L 135– 145 mEq/L 9/15/1 9 136 3.5-5.0 mEq/L 9/15/1 9 3.0 Patient Information (1) Name: A.J. Age: 65 Gender: F Code Status: Full Resuscitation DPOA: None Living Will: None 2.4 H Chief Complaint Surgical History Patient presents to the ER with complaints of nosebleed Implantable Cardioverter Defibrillator on 06/23/2017 PICC line on 09/11/2019 Admitting Diagnosis Acute on chronic systolic and diastolic CHF Social History 7.60 Medical Management/ Orders/ Medications & Allergies (2) 28.0 L Name Dose RT Freq . 1mg4ml IV Pus h Dail y 80mg/ hr IV 9.3 L MOA Lactulose . Bumetanide Rifaximin Protonix Medical History Ms. A.J. is a 65 year old Jamaican female with an extensive past medical history of end-stage liver disease with hepatic encephalopathy, CHF, atrial fibrillation, valve replacement requiring Coumadin, prior cardiac arrest and an Implantable Cardioverter Defibrillator (ICD) placement who initially presented to FMC ER from nursing home on 09/10/2019 with epistaxis. Patient’s epistaxis was controlled with silver nitrate cauterization packing in the ED. She was upgraded to ICU to worsening bleed and subsequently required intubation for airway protection with worsening encephalopathy an high risk of aspiration on 09/11/2019. She was provided with Fresh Frozen Plasma (FFP) and bleeding is now controlled. An ammonia was drown, patient is severe lethargy, and came back elevated at 141. Patient is on Lactulose and Rifaximin. Patient is allergic to Penicillins and Tape. ` RN Considerations Onset/Peak/ Duration (Insulin) Patient lives in a nursing home. He has three daughters and two sons. Patient used to smoke and consume alcohol occasionally. There is no history of drug consumption. Priority nursing diagnosis #1 Vital Signs (4) Neurological (5) Cardiovascular (6) Atrial Fibrillation Respiratory (7) Priority nursing diagnosis #2 Bleeding related to Coumadin use as evidence by……… Temperature: 98.7 F Pulse: 65 Respiratory Rate: 21 BP: 120/56 SpO2: 100 09/15//2019 Patient is confused Currently disoriented X4 Sedated Worsening Encephalopathy Implantable Cardioverter Defibrillator on 06/23/2017 Coumadin 2mg qd for life saving purposes Acute ventilatory dependent. Respiratory failure. Patient was intubated for airway protection on 09/11/2019 Altered cardiac status related to fluid volume overload/ CHF as evidence by…….. GI (9) GU (10) Rest/ Exercise (11) Epistaxis with concern of GI bleed in the setting of coagulopathy. Abdomen is nondistended And soft Folic Catheter in place Acute kidney injury with worsening azotemia Acute GNR cystitis Status: Bed Needs total assistance ICU monitoring Psychosocial (14) Misc. (Ht/Wt) Nutrition/Hydration (8) ETand OG tube in place 09/11/2019 Outcome/Goal #1 Patient’s bleeding will be controlled and vital signs returned to baseline within normal limits. Integumentary (12) Endocrine (13) Skin is intact Nopressure ulcers PICC line inserted on 09/11/2019 • • • • • • • • Interventions #1 Observe for change in mental status Observe for changes in skin color, turgor and temperature Monitor for tachycardia and hypotension Monitor and record blood loss Monitor CBC, PT, PTT Monitor procedural site for further signs and symptoms of bleeding. For bleeding apply direct manual pressure to procedural site and notify physician Report any change of vital signs or procedural site to the physician Blood Aspiration Admission weight: 190 lb Height: 5’2 Interventions # 2 • Assessment/ Evaluation #2 Assessment/ Evaluation #1. PC Outcomes/Goal Potential Complications/ at risk for Outcome/Goal #2 Patient will have optimal cardiac functions PC Interventions Administer medications IV drips as needed • Monitor Electrolytes/EKG’s and Cardiac Enzymes as ordered • Monitor vital signs/Hemodynamics, rhythm strips and report changes to physicians • Report malfunctioning pacer and AICD to Physician …….. PC Evaluation Plan References

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