NURSING STUDENT

PATIENT ASSESSMENT

Neurological/ Neurosensory
(Describe assessed finding here normal and abnormal)
1. The pt.s LOC was 7/15 on the GCS. Eyes open to pain (2), pt.s legs flexed (4), pt.
was non-verbal (1). Awake and A&O unable to access.. Pt. sedation scale of 5.













2. Pupils reactive to light, PERRL, 4 mm. Strength (5) Full power.
3. Sensation appears normal as pt. appears to feel pain when the shoulder that
recently had Sx. was moved.

4. Pain 5 on FLAAC.






5. Coordination, dexterity, and fine movement were unable to be assessed due to pt.
being on soft restrains and sedated.
6. Touch, smell and vision were unable to be assessed due to pt. being sedated.
7. Gross movement intact.
8. Pt. is deaf on both ears.

9. Pt. Hx. of Cerebral Palsy (CP).





10. Hx. of Stroke.

Interpret any abnormal clinical manifestations

1. The pt. LOC was decreased due to the pt. being partially sedated as a result of being
on a ventilator. Sedatives are necessary to decrease the anxiety and discomfort that
pt.s experience while intubated (Lewis et al., 2011, p. 1702). Although the
assessment was performed during the pt.s sedation vacation, only midazolam
(Versed) had been stopped infusing while fentanyl (Sublimaze) continued to be
infused. fentanyl (Sublimaze) was not stopped because of the pt.s Hx. of chronic
pain and extensive use of home medication for the Tx. of pain. The pt.s GCS (7) was
determined based on her response to pain: simultaneously opening her eyes (2),
flexing her legs (4), and trying to turn. However, the pt. was non-verbal (1) (Lewis et
al., 2011, p. 1434). The pt. was described as non-verbal (1), but it is important to
note that the pt. is deaf on both ears and mainly uses ASL to communicate.
Communication via ASL was impaired by the need for soft wrist restrains. Pt. was
awake at times, but A&O was unable to be determined due to semi-sedated state
and communication barrier. Pt. sedation scale was determine as 5 as pt. was mostly
asleep but responded to pain (Lewis et al., 2011, p. 139).
2. WNL
3. Pt. showed s/s of pain as grimacing and trying to pull back when her Lt. arm was
moved. Pt. had a complete Lt. shoulder replacement x3 weeks ago.
4. Pt. showed occasional grimace (1), legs were drawn up (2), and pt. was arching (2)
(National Hospice and Palliative Care Organization online). Pt. has a Hx. of chronic
back pain r/t a car accident injury that resulted in neck surgery. Pt. also has a Hx. of
degenerative disc disease and recent complete replacement of Lt. shoulder to Tx. a
frozen shoulder secondary to Fx. Additionally, pts. with Cerebral Palsy (CP) may
experience post-impairment syndrome which can manifest as pain, increase risk for
osteoarthritis and degenerative arthritis, and chronic pain (National Institute of
Neurological Disorders and Stroke Online).
5. See item 1.

6. See item 1.
7. WNL.
8. Pt. has a Hx. of CP. One of the manifestations of CP can be deafness (McCance et al.,
2010, pp. 675-6).
9. CP can result from either genetic or environmental factors. The cause of the pt.s CP
is unk. Pt. does present with s/s of pyramidal/spastic CP per family. She has
contractures of her feet, is deaf, has a Hx. of respiratory problems (aspiration PNA),
orthopedic disabilities (WC bound) (McCance et al., 2010, pp. 675-6), pain, and
swallowing difficulties (National Institute of Neurological Disorders and Stroke
Online).
10. The time of the stroke was not included in the pt.s H&P. It is possible that the

XI. Comprehensive Care Plan 1

11.
12.
13.

14.
15.
16.

Hx. of dysphagia.

CT of Head with contrast on 2/2/15 No obvious nonconstrast CT finding; brain
death cannot be evaluated by noncontrast CT brain exam.

Pt. sedated with fentanyl (Sublimaze) and midazolam (Versed). propofol
(Diprivan) discontinued.




Hx. of chronic back pain Tx. with a baclofen pump. Other home medications
include: Medical marijuana, methadone (Dolophine), pregabalin (Lyrica),
hydromorphone (Dilaudid)
methadone (Dolophine) TID to Tx. severe pain. QUEtiapine (Seroquel) as an
adjunctive tx. for pain.
Bolus fentanyl (sublimaze) 50 mcg/mL as PRN for pain.

11.
12.
13.

14.
15.
16.

NURSING STUDENT
stroke was when the pt. was an infant leading to her CP. If the stroke was when the
pt. was an adult, because of her Dx. of CP, the pt. does have risk factors for strokes.
CP pts. age prematurely age is a significant risk factor for strokes. Additionally, the
pt. is on multiple drugs to Tx. her chronic pain and her family suggests that she
abuses these drugs. Finally, because of her CP, pt. has limited to no physical exercise
(Lewis et al., 2011, p. 1461).
The pt.s Hx. of dysphagia may be r/t her Hx. of stroke (Lewis et al., 2011, p. 1464) or
her CP (National Institute of Neurological Disorders and Stroke Online).
WNL. Confirmatory test for Brain Death include Cerebral angiography,
electroencephalography, transcranial Doppler ultrasonography, and Cerebral
scintigraphy (University of Miami Miller School of Medicine Online).
Although the pt. is now ventilated via a tracheostomy, she cont. to become agitated
during her sedation vacations. This results in the pt.s need to continue to be
sedated to blunt her anxiety and discomfort r/t the tracheostomy and ventilator
(Lewis et al., 2011, p. 1702). propofol (Diprivan) was discontinued because there is
an order to progress with the ventilation weaning procedure and decreased sedation
is require to assess the pt.s tolerance to the weaning process.
See item 5 for explanation of causative factors for the pt.s chronic pain.


See item 5 for explanation of causative factors for the pt.s chronic pain.

Bolus fentanyl (Sublimaze) could be use for acute onset of pain. It is possible that
the pt. is experience pain r/t aspiration of foreign object and inflammation r/t Sx.
procedures.

Only required on the comprehensive care plan

Note if a patient has normal clinical manifestations i.e. if the patients ABGs are normal but the patient is on a mechanical ventilator explain

References: See reference Page

XI. Comprehensive Care Plan 2

NURSING STUDENT
PATIENT ASSESSMENT
Oxygenation / Cardio pulmonary
1. Pt. adm. for Acute Respiratory Failure after an episode of Acute Respiratory
Arrest.

2. Lactate was 14.3 on DOA.



3. Flexible and rigid bronchoscopy for removal of airway foreign body (chicken 2.5 x
2 x 0.7 cm) on left main bronchus x3 (02/01-03/15)
4. cXR showed bilateral alveolar infiltrates which worsen on 2/2/15.

5. Direct Laryngoscopy revealed Rt. vocal chord lesion that originally interfered with
intubation. Biopsy of the mass performed on 2/5/15.

6. O2 adm. via tracheostomy. Shiley 8.0 mm.

7. Pt. on ventilator CMV, Tv 600 mL, FiO2 0.4, RR 16, PEEP 5.
Pt. RR on ventilator was 20.











8. During ventilation weaning trial the RR ranged from 40-48.
PaO2 96.9 , FiO2 0.4, PaO2/FiO2 ratio 242.25, PEEP 5, pH 7.558, Hemodynamically
stable, spontaneous breath (RR 20 for ventilator setting of RR 16), Cause of acute
respiratory failure was aspiration of foreign object.
9. Small, thick and pink/red sputum that required to be suctioned.
Crackles throughout all lung fields.
10. Breaths of full character on ventilator, shallow during the ventilation trial.
11. Pt. receiving hydrocortisone PF (SoluCORTEF).

Interpretation
1. The aspiration of a foreign object lead to decreased respiratory gasses reaching the
alveoli that lead to a V/Q mismatch that resulted in acute respiratory failure (Lewis
et al., 2011, pp. 1744-51).
2. Lactate levels are increased as a result of the pt. experiencing severe trauma (Acute
Respiratory Failure) (Kee, 2010, p. 269). Studies have shown that pt. with pulmonary
injury result in pulmonary tissue releasing lactate into the circulation (Brown et al.,
1996).
3. Bronchoscopy is a Dx. study use to remove foreign objects (Lewis et al., 2011, p.
514). Pt. showed no s/s of hemorrhage after procedures.
4. Alveolar infiltrates are clinical manifestations to Acute Respiratory Failure (Lewis et
al., 2011, pp. 1744-51) and PNA (McCance et al., 2010, pp. 1327-8).
5. During the pt.s intubation, a mass on the Rt. vocal chord was observed. It was
difficult to intubate the pt. and it required two different attempts (Pt.s charts
notes). A biopsy of the mass was taken on day of care.
6. A tracheostomy is performed when the need for artificial airways is expected to be
long (Lewis et al., 2011, p. 1698).
7. The pt. experience acute hypoxic respiratory failure secondary to aspiration of
foreign object AEB on DOA she was on FiO2 1.0 and her PaO2 was 38.8. PaO2/FiO2
ratio was <200. The pt.s ventilator was set to CMV as indicated for acute
respiratory failure (Lewis et al., 2011, 1705). The pt. was weaned from FiO2 1.0 to
FiO2 0.4 on 2/3/15 as a result of increase PaO2 (103.6). Originally the pt. was
receiving a Tv of 500 mL but her O2sat was 53.5. The Tv has been changed to 600 mL.
The pt.s PaO2 has ranged from 73.3 to 96.9 since the change to FiO2 0.4 and O2sat
has remained above 93%. The respiration rate was 20 on the DOA but decreased on
2/2/15 as a result of the pt. developing respiratory alkalosis. Although the ventilator
program is set for a RR of 16, the pt. has a RR of 20 that contributes to the
development of respiratory alkalosis (Lewis et al., 2011, p. 322). PEEP is
recommended for pt. with severe hypoxemia and for pts. with decreased lung
compliance and stiffness (Lewis et al., 2011, p. 1707).
8. The pt. failed to pass the weaning trial as her RR was >38 min. The pt. met weaning
readiness criteria as her PaO2/FiO2 ratio was >150-200, PEEP 5-8 cm H2O, FiO2 0.4-
0.5, pH 7.25, Hemodynamically stable, shows spontaneous breathing efforts and
had a reversible underlying cause. (Lewis et al., 2011, p. 1712).
9. Clinical manifestations of PNA include sputum and crackles (Lewis et al., 2011, p.
549).
10. Breaths were shallow during weaning trial as a result of the elevated RR (40-48).
11. Tx. of inflammatory process r/t aspiration of foreign object and PNA infection
(Vallerand et al., 2013, p. 363). An inflammatory process leads to further tissue
damage that increases the secretions to alveoli (McCance et al., 2010, pp. 1327-8)
possibly exacerbating the Dx. of acute respiratory failure.

XI. Comprehensive Care Plan 3

12. RT with ipratropium-albuterol (DUO-NEB) q4h.

13. ABGs pH 7.558, pCO2 27, HCO3 23.5, PaO2 96.9, O2Sat 97.1 Respiratory Alkalosis







14. RBC 3.78 (Decreased from 3.98 on DOA to 3.61 on 2/4/15)
Hbg 10 (Decreased from 10.4 on DOA to 9.4 on 2/4/15)
Hct 30.5 (Decreased from 32.8 on DOA to 28.8 on 2/4/15)
15. SR that converts to ST (HR 109) when agitated during sedation vacation.


16. S1, S2. No Pacemaker. BP 124/59. Peripheral pulses (Radial and Pedal) +2 equal
x4. Capillary Refills <3 sec. Nail bed pink with no s/s of clubbing. Pink moist skin.
17. Non pitting Edema +2 on hands


18. Troponin I 0.052 on DOA. BNP 33 on DOA.
19. Myoglobin was 303 on DOA.


20. ECG 2/1/15: ST. Consider RA enlargement P> 0.24 mV. Repolarization is
abnormal suggesting ischemia.


21. No s/s of DVT. Pt. on knee high intermittent sequential pneumatic compression.
Pt. receives enoxaparin (Lovenox) 40mg.
Platelet count 213 on 2/5/15 (Decreased from 444 on DOA to 210 on 2/4/15).
PT was 15.2, INR 1.3, and APTT 33.7 on DOA.

NURSING STUDENT
12. The combination of an anticholinergic and a bronchodialator help relax and open the
airway to increase the amount of air reaching the alveoli (Daviss Drug Guide Online).
This improves the V/Q ratio.
13. On the DOA the pt. arrived on severe metabolic acidosis (pH 7.124 and HCO3 13.1)
most likely as a result of bicarbonate loss of unk. origin (pt. has no Hx. of diarrhea or
home medications that lead to the depletion of serum bicarbonate) and lactic
acidosis (Lactate 144) (Lewis et al., 2011, p. 322). With endotracheal ventilation, pt.
developed respiratory alkalosis (pH7.476-7.558) as a result of alveolar
hyperventilation (Lewis et al., 2011, pp. 1708-9). The RR setting was decreased from
20 to 16 but the pt. continued to breath at a RR 20. Alveolar hyperventilation can
also occur as a result of an increased Tv (Lewis et al., 2011, pp. 1708-9).
14. RBC and H&H are WNL. The decrease seen throughout hospitalization is the result
of hemodilution (Kee, 2010, pp. 220, 222, and 365) as pt. has had a net gain of fluids
of + 6,647 mL.
15. ST is associated with physiological and psychological stressors such as pain (increase
perception of pain as a result of sedation vacation) and anxiety (anxiety associated
with mechanical ventilation) (Lewis et al., 2011, p. 824).
16. WNL

17. Edema is the result of increased hydrostatic pressure and decreased oncotic
pressure (Lewis et al., 2011, p. 306) as a result of IVF adm. and net intake since DOA
of 6,647 mL. See item Metabolic /Fluid and Electrolytes 7
18. WNL
19. Elevated as a result of trauma/injury - acute respiratory failure secondary to
aspiration of foreign object. Although it shows muscle injury, it is non-specific.
Myocardial injury is ruled out due to Troponin I WNL. (Kee, 2010, p. 299)
20. ECG are not definitive diagnostic test for RA enlargement. There are no clinical or
pathological finding suggesting COPD, pulmonary hypertension, or congenital heart
disease. Other diagnostic tests should be order to r/o RA enlargement (Harrigan and
Jones, 2002).
21. DVT prophylaxis include the use of sequential compression devices and prophylactic
use of anticoagulant medication (Lewis et al., 2011, p. 579).
Platelets are WNL and the continuous decrease from DOA to day of care is related to
the hemodilution discussed on item 14.
Coagulation panel WNL.
Pt. is on hydrocortisone (SoluCORTEF) that has Thromboembolism as a potential
adverse effect (Vallerand et al., 2013, 363).

XI. Comprehensive Care Plan 4

NURSING STUDENT


Metabolic / Fluids and Electrolytes
1. Pt. admitted with severe metabolic acidosis.
2. Na ranged from 139-142 from DOA to day of care.
3. K decreased from 4.3 (2/2/15) to 3.5 (2/5/15).


4. Cl ranged from 103-111 from DOA to day of care.

5. CO2 content ranged from 16-28 from DOA to day of care.


6. Glucose decreased from 234 on DOA to 114 on day of care.


7. Total Intake since DOA +11,551 mL. Total output since DOA -4,902 mL. Net I/O
since DOA +6,647 mL.




8. BUN ranged from 11-21 from DOA to day of care.
9. Cr ranged from 0.6-0.5 from DOA to day of care.
10. T. Billirubin was 1.2 on 2/2/15.

11. ALP was 141 on DOA.

12. AST was 94 on 2/2/15.

13. ALT was 44 on 2/2/15
14. Anion gap ranged from 4-21 from DOA to day of care.

Interpretation
1. See item Oxygenation/ Cardio pulmonary 13
2. WNL
3. WNL. Potassium levels can decrease due to trauma/injury (acute respiratory failure
secondary to foreign object aspiration) and malnutrion (NPO status) (Kee, 2010, p.
335). Pt. received KCl 40 mEQ on 2/4/15 to Tx. borderline low K levels (3.5).
4. Cortisone preparation such as hydrocortisone PF (SoluCORTEF) can increase Cl levels
(Kee, 2010, p. 2004 )
5. Decreased CO2 content on 2/1-2/15. See item Oxygenation/ Cardio pulmonary 13.
CO2 may start to increase as a result of adm. of steroid preparation such as
hydrocortisone (SoluCORTEF) (Kee, 2010, p. 107)
6. Glucose levels are increased as a result of stress r/t acute respiratory failure
secondary to aspiration of foreign object. Glucose levels also increased r/t PNA.
(Kee, 2010, p. 204). Glucose levels decrease as pt. receives Tx.
7. Pt. receiving LR at a rate of 75 mL/h. Decrease urinary output accounts for net
intake of fluids. Decrease urinary output r/t stress (acute respiratory failure
secondary to aspiration of foreign object, multiple Sx.) that leads to increase
aldosterone and ADH secretion (Lewis et al., 2011, p. 377). Decrease urinary output
related to Positive Pressure Ventilation with PEEP (Lewis et al., 2011, p. 1709) that
decreases CO resulting in decrease renal perfusion.
8. WNL
9. WNL
10. T. Billirubin increased from 0.3 on DOA to 1.2 on 2/2/15 as a result of the adm. of
medication such as hydrocortisone (SoluCORTEF) (Kee, 2010, p. 77).
11. ALP may be elevated on non-fasting pts (Lexicomp Online). Pt. was adm. after
aspirating on foreign object (chicken) while having a meal.
12. AST are elevated as a result of the pt.s frequent use of home medications for the Tx.
of pain such as methadone and hydromorphone (Kee, 2010, p. 69).
13. WNL
14. Elevated Anion Gap (21) on DOA is related to metabolic acidosis. See item
Oxygenation/ Cardio pulmonary 13 for explanation. Anion Gap decreased on 2/2/15
as a result of increased HCO3 content (See item 5). Anion Gap continues to decrease
as pt. respiratory alkalosis continues to develop (See item Oxygenation/Cardio
Pulmonary 13) (Kee, 2010, p. 39).

XI. Comprehensive Care Plan 5

NURSING STUDENT
Endocrine
1. Pt. has a Hx. of Hypothyroidism. No laboratory diagnostic test for the
determination of the presence of hypothyroidism. Pt. is not taking any home
medication for the Tx. of Hypothyroidism.
2. No current endocrine problem. Pt. is not on estrogen or steroid treatment.
3. Pt. has not been Dx. with diabetes. No s/s of hyperglycemia or hypoglycemia. Pt.
is not receiving home medications for Diabetes 1 or 2. Not insulin dependent.
4. Sexual function could not be assessed.
5. Secondary sex characteristics are present. Breasts are developed and pubic hair is
present.


Nutrition
1. Pt. was NPO

2. Pt. had PEG Tube.
When NPO status is changed, pt. receives continuous tube feeding with Replete (1
cal/ml high protein) formula at a rate 60 mL/h









3. Pt. adm. weight was 48 kg (2/1/15). No weight change to day of care (2/5/15).

4. Ca ranged from 7.8 to 8.7 from DOA to day of care.
Total protein was 6.1 on 2/2/15.
Albumin was 3.4 on 2/2/15.

5. Pt. takes ferrous sulfate ER (Slow FE) at home.

6. Globulin 2.7 on 2/2/15.

Interpretation

WNL

Interpretation
1. NPO status order by MD prior to Sx. on day of care to reduce the risk of pulmonary
aspiration (Lewis et al., 2011, 344).
2. Pt. was admitted with a non-patent PEG tube (PEG tube placed in 2003). Pt.s sister-
in-law informed it was decided to keep the PEG tube easily accessible due to the
need for enteral feedings when pt. becomes ill and hospitalized. Feeding through
PEG started on 2/2/15. PEG tubes decreases the risk for aspiration.
Pt.s on positive pressure ventilation are in a hypermetabolic state r/t critical illness
which requires increase nutritional needs. Because of the placement of an ET or
new tracheostomy, pts dont have a normal route for eating available requiring
either NG or PEG feedings. Inadequate nutrition may delay the weaning ventilation
process. Formula is high on protein to meet caloric needs and low in carbohydrate
to reduce avoid increased bicarbonates that would lead to a need for higher minute
ventilations. High protein enteral feedings prevent muscle loss that would increase
respiratory muscle impairment (Lewis et al., 2011, pp. 1710-11).
3. No weight change r/t positive net intake. See item Metabolic/Fluid and Electrolytes
7.
4. Impaired nutrition r/t Hx. of Dysphagia. See item Neurological/Neurosensory 10 and
12.
Total Protein and Albumin levels are also decreased as a result of hypermetabolic
state of critically ill pts (See item 2).
5. Increased iron availability may promote bacterial growth (Medscape.com). Pt. was
admitted with PNA (Klebsiella oxycota).
6. WNL

XI. Comprehensive Care Plan 6

NURSING STUDENT

Elimination
GI
1. Active BS. Abdomen soft and non-distended. Last BM 2/4 x6 Formed, Brown, and
Soft. Evidence of BM seen on 2/5 while performing pericare.
2. Incontinent
3. Pt. to receive lansoprazole (Prevacid Solutab) when no longer on NPO status.

GU
1. Pt. had indwelling catheter.

2. Urine is clear, yellow and odorless. Urine output ranged from 0.87 to 1.61
ml/kg/hr
3. Frequency, Urgency, Dysuria, Nocturia unable to be assessed at this time as pt. is
sedated and has an indwelling catheter.

Skin Integrity / Immunity
1. Pt. had bruises on both wrists.

2. Pt. had no rashes, sores or abrasions. Pt. heels are red but blanching.

3. Pt. had a dressing on Rt. neck. Dry and intact.
4. Double Lumen Power PICC 5Fr line on Rt. forearm. Patent.


5. Pt. had sutures around tracheostomy. Wound clean and intact.
6. Skin is pink and moist. Nails are intact. Hair is intact. Body temp. warm. Mucous
membranes moist. Skin Turgor non-tenting.
7. Non-pitting edema +2 on both hands.
8. WBC 16.5 on 2/5/15 (25.1 on 2/2/15)
Neutros 96.3,Bands 26, Lymphs 2.6, and Monos 1.1 on 2/2/15
Sputum culture revealed Klebsiella Oxytoca
cXR showed bilateral alveolar infiltrates which worsen on 2/2/15 suggestive of
PNA
Pt. receiving levofloxacin (Levaquin).



9. Pt. does not have isolation precautions.
10. Hx. of aspiration PNA.
11. Blood culture negative.

Interpretation
GI
1. WNL

2. Pt. is sedated (See Item Neurological/ Neurosensory 1).
3. Pts. receiving mechanical ventilation are at risk of developing stress ulcers (Lewis et
al., 2011, p. 1709). Prophylactic Tx. for stress ulcers (Vallerand et al., 2013, p. 763).
GU
1. Need for accurate I/O r/t to urinary retention (See item Metabolic / Fluid and
Electrolytes 7). Pt. is sedated (See Item Neurological/ Neurosensory 1).
2. WNL

3. Pt. is sedated (See Item Neurological/ Neurosensory 1).

Interpretation
1. Collection of extravascular blood in dermis and subcutaneous tissue as a result of
trauma (daily collection of arterial blood samples) (Lewis et al., 2011, p. 444)
2. WNL. However, pts immobility and impaired nutrition puts the pt. at risk for
pressure ulcers (Ackley et al., 2012, p. 378).
3. Pt. had a central venous line upon adm. WNL.
4. Recommended for pts. who will need vascular access for periods between 1 wk to 6
months. PICC lines have lower incidence of infection related to central venous lines
(Lewis et al., 2011, p. 329). WNL
5. Need for tracheostomy see item Oxygenation/ Cardio Pulmonary 6. WNL.
6. WNL

7. See item Oxygenation/ Cardio Pulmonary 17 and Metabolic/Fluid and Electrolyte 7.
8. Clinical manifestation of PNA increased WBC, neutrophils and bands as a result of
immunological response to bacterial infection (Klebsiella oxytoca) (McCance et al.,
2010, pp. 1327-8 and Kee, 2010, p. 435). Neutrophils are the first line of defense,
increased number of bands (immature neutrophils) show rapid multiplication of
neutrophils to fight acute bacterial infection (Kee, 2010, p. 437). Lymphs and Monos
are decreased as percentages are altered by changes in other leukocytes.
Klebsiella oxytoca is a common pathogen r/t PNA (Medscape.com).
WBC on a downward trend r/t adm. of levofloxacin (Levaquin) an antibiotic used to
Tx. Gram Negative Bacteria (Vallerand et al., 2013, p. 580).
9. WNL
10. R/t Hx. of Dysphagia See item Neurological/Neurosensory 10 and 12.
11. WNL

XI. Comprehensive Care Plan 7

NURSING STUDENT
Activity and Rest
1. Pt. orders for Bed Rest with HOB at 30

2. Pt. orders for soft wrist restrains.
3. Pt. orders for passive ROM q2h.

4. Interrupted sleep while on sedation vacation r/t pain.
5. No cast, braces, or traction.
6. Pt. was risk for injury/fall.
Bed rails up x2.



7. Pt. is WC bound.
Contractures of the feet.
8. Gross movement intact. Pt. is able to move legs and arms.
9. Hx. of Degenerative disc disease and Frozen Lt. shoulder secondary to Fx.
(Complete shoulder replacement x3 weeks ago).

Interpretation
1. Pt. is WC bound. HOB at 30 as part of the guidelines for VAP prevention (Lewis et
al., 2011, p. 1709).
2. R/t risk for unplanned extubation (Lewis et al., 2011, p. 1703).
3. Prevention of contractures as a result of immobilized extremities (Lewis et al., 2011,
p. 1577)
4. See item Neurological/Neurosensory 5
5. WNL
6. FRAT of 13. Pt. had no Hx. of recent falls (2), pt. on more than medication that have
sedative effects (4), pt. has a Hx. of anxiety and depression but not affected at this
time (3), pt. has altered cognitive status r/ t sedation (4). Pt. is a Medium risk for fall
while on sedation vacation (FRAT Saddleback Hospital). Follow standard safety
precautions.
7. See item Neurological/Neurosensory 10

8. WNL
9. See item Neurological/Neurosensory 5 and 10.

XI. Comprehensive Care Plan 8

NURSING STUDENT
PSYCHOSOCIAL ASSESSMENT
Culture / Ethnicity / Spirituality

1. Deaf culture. ASL speaking.







2. Caucasian



3. Jewish

Developmental / Role
1. Primary: Generative vs. stagnation. Actual unable to be determined as pt. was
sedated. (Female 63 yo)





2. Secondary: Partner, Dependent, Sick Role

Interpretation
These are interpretation based on information provided by the pt.s family as pt. is
sedated.
1. Causative reason for deafness see item Neurological/Neurosensory 9.
Deaf people identify themselves as being part of the deaf culture if they prefer to
communicate using primarily ASL (Meador and Zazove, 2005). Pt. prefers to
communicate with ASL.
ASL has different idioms, grammar and structure than spoken English. Because of
this, deaf people may have a health care deficit in comparison to a hearing person
(Meador and Zazove, 2005).
2. Pt. is dependent on life partner for care. However, her life partner values
independence, freedom and self reliance (Lewis et al., 2011, p. 24) as he does not
want to place pt. on Kindred care. Pt.s life partner might not understand the
severity or complexity of the pt.s care needs due to a communication barrier (see
item 1).
3. Pt. might value religion AEB life partner requesting prayer from a Rabbi.
Pt. and life partner are not married which is accepted by the Jewish culture and
religion. Marriage is considered a private contractual agreement that does not
require the presence of a rabbi. An official wedding is not necessary (Jewfaw.org).
Interpretation
1. During this stage, the pt. is expected to be working towards achieving life goals that
have been established by herself while considering the wellbeing of future
generations. Upon achieving the task, the pt. might experience a sense of
gratification and satisfaction with her life. The absence of achievement may result in
a person who is withdrawn and isolated (Townsend, 2011, p. 24). The pt. does not
appear to have achieved a sense of gratification and/or satisfaction with her life as
she is prone to withdrawal and isolation (See item Self Concept 3)
2. Pt. is WC bound and dependent on life partner. Pt. has been seriously ill on an off
since 2003. This has been her longest hospitalization. See item Self Concept 4 and
Relationships 2.

XI. Comprehensive Care Plan 9

NURSING STUDENT
Self Concept
1. Self-esteem and body image self concept were unable to be determined at this
time as pt. was sedated.
2. Pt. is in a heterosexual relationship with a life partner x25 years.

3. Coping style: Withdrawal and Isolation per sister-in-law.



4. Grooming and hygiene were fair.





5. Speech and Tone were unable to be assessed as pt. was sedated.
6. Pt. was agitated during the ventilator weaning trial.
Haloperidol (Haldol) 5 mg/mL PRN agitation.
Relationships
1. Pt. on a dependent heterosexual relationship with a life partner who is HOH and
possibly has a mental delayed x25 years.
2. Pt. and life partner depend on life partners sister.

Interpretation
1. See item Neurological/Neurosensory 1

2. Pt. is in a relationship that is accepted both for her culture and religion. See item
Culture/Ethnicity/Spirituality 3.
3. Hx. of depression and anxiety. Tx. with mirtazapine (Remeron). Pt.s sister-in-law
reports that pt. might abuse pain medication in order to cope with anxiety. Pt.s
sister-in-law also reports that pt. had been home bound for many months and on
DOA it had been the first time that she had felt like leaving her home.
4. Grooming and hygiene were fair most likely as the result of the pt. depending on life
partner for care. Life partner appears to have mild developmental delay that could
impair with the care of the pt. What is perceived as a delay could also be the result
of differences between ASL and English that can be communication barriers that
impair health care knowledge. Pt.s life partner might not understand the severity of
the pt.s illness and care needs.
5. See item Neurological/Neurosensory 1
6. Pt. agitation r/t presence of tracheostomy and Hx. of anxiety. See item
Neurological/Neurosensory 1 and Self Concept 3
Interpretation
1. Pt. is in a relationship that is accepted both for her culture and religion. See item
Culture/Ethnicity/Spirituality 3.
2. See item Self Concept 4

XI. Comprehensive Care Plan 10