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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Excellent | Good | Fair | Poor | ||
Main Postinga | 45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.
Supported by at least three current, credible sources.
Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.
At least 75% of post has exceptional depth and breadth.
Supported by at least three credible sources.
Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
35 (35%) – 39 (39%)
Responds to some of the discussion question(s).
One or two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with two credible sources.
Written somewhat concisely; may contain more than two spelling or grammatical errors.
Contains some APA formatting errors. |
0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible sources.
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style. |
|
Main Post: Timeliness | 10 (10%) – 10 (10%)
Posts main post by day 3. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not post by day 3. |
|
First Response | 17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
15 (15%) – 16 (16%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
13 (13%) – 14 (14%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
Second Response | 16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
12 (12%) – 13 (13%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
Participation | 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days. |
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Total Points: 100 | |||||