NURSING CARE PLAN

Actual Threats
Assessment
Subjective:
none
Objective:
GCS 3-4
(E1V1M1-2)
Vital Signs
(9/18/16)
BP: 180/140
PR: 62 bpm
RR:
regulated at
18 cpm on
mechanical
ventilator,
AC mode,
40% FiO2,
TV: 500
ABG (9/18/16)
pH: 7.37
pCO2: 35
pO2: 218
HCO3: 20.2
O2 Sat:
100%
(+)
spontaneous
breathing

Diagnosis

Planning

Intervention

Ineffective
Airway
Clearance
related to
altered level
of
consciousness
evidenced by
patients GCS
of 3-4
(E1V1M1-2)

Short Term
Goal:
After an hour
of nursing
intervention,
the patient
will maintain
a patent
airway and
ensure
ventilation

Independent:
Monitor vital
signs and GCS
hourly
Monitor blood
gas values and
pulse oxygen
saturation

Long Term Goal:

After 2 day
of the
nursing
process, the
patient the
results from
the previous
lab tests will
decrease
within
normal limits
as displayed
in the
following
normal
values:

Perform
nasotracheal
suctioning as
ordered

Position head on
semi-Fowlers
position

Dependent:
Administer the
following
medication:

Rationale

To assess
trends in vital
signs and GCS
for baseline
data
Normal blood
gas values are
a PO2 of 80100 mmHg
and a PCO2 of
35-45 mmHg.
An oxygen
saturation of
less than 90%
hypoxemia.
Facilitates
removal of
thick mucus
plug.
Reduces
arterial
pressure by
promoting
venous
drainage

Evaluation
Short Term
Goal:
After an hour of
nursing
intervention,
the patient
maintains a
patent airway
and ensure
ventilation
Goal met
Long Term
Goal:
After 2 day
of the
nursing
process,
the patient
the results
from the
previous lab
tests will
decrease
within
normal
limits as
displayed in

Vital Signs
(9/18/16)
BP: 90120/6080 mmHg
PR: 80100 bpm
ABG
pH: 7.357.45
pCO2: 3545
pO2: 80100
mmHG
HCO3:
22-26
mEq/L
O2 Sat:
97%100%

on NGT
on cardiac
monitor
on NaHCO3
drip
on PNSS 1L x
12
on Foley
catheter

Fluimicil
600mg/tab
twice a day
dilution in
50cc water
as ordered.
Ipratropium
bromide +
Salbutamol
nebulization
every 6
hours
Omeprazole
40mg/cap
once a day
Cerebrolysin
3 amp in
70cc PNSS
once a day
Citicoline 1 g
IV every 12
hours

Report any
untoward
contraindication
s to AP.

It is used as a
mucolytic
agent to
reduce the
viscosity of
mucous
secretions.

Used to control
and prevent
symptoms
caused by
ongoing lung
disease.
It works by
blocking acid
production in
the stomach.
Organic,
metabolic and
neurodegenera
tive disorders
of the brain
Symptoms and
signs of
cerebral
insufficiency.
To provide
updates for the
AP

Subjective:

Ineffective

Short term goal:

Independent

the
following
normal
values:
Vital Signs
(9/20/16)
BP:
140/100
mmHg
PR: 82
bpm
ABG
(9/20/2016)
pH: 7.38
pCO2: 32
pO2: 74
mmHG
HCO3:
18.8
mEq/L
O2 Sat:
89%
Goal partially
met, endorse
results to the
next nurse on
duty.

Short term

none
Objective:
Temp: 38. 4C
Skin warm to
touch
On and off
fever
CBC (9/20/16)
WBC: 24.2
Segmenters:
0.93
Lymphocytes:
0.07
Endotracheal
aspirate gram
stain
(9/19/16)
Epithelial cells:
few
Pus cells:
>50/hpf
Gram(+) Cocci
(Singly/In
pairs): 3+
Gram (-)
Bacilli: few
(+) yellowish
secretions

Thermoregula
tion related to
on and off
fever as
evidenced by
acquired body
temperature
of 38. 4C

After an hour
of nursing
intervention,
the body
temperature
of the
patient will
decrease
from 38. 4C
to 37. 6C

Long term goal:

At the end of
the shift, the
patients
results from
the previous
lab test will
decrease
within
normal limits
as displayed
in the
following
normal
values:
WBC: 4.5011.00
Segmenters
: 0.55-0.65
Lymphocyte
s: 0.25-0.35

Monitor the
temperature
hourly
Provide loose
clothing
Provide a cool
environment
Apply tepid
sponge bath
Advise
significant
others to wear
PPE upon
entering the ICU

Dependent
Administer the
following
medications as
ordered
Aeknil 1 amp
every 4 hours
as ordered
Piperacillin +
Tazobactam
2.25 g via IV
every 5 hours

To assess
trends in vital
signs and GCS
for baseline
data
To promote
comfortability
To promote
comfortability
To help lower
the body
temperature
To prevent
spread of
infection

To help lower
the body
temperature

Treating
moderate to
severe
infections
caused by
certain
bacteria.

goal:
After an
hour of
nursing
intervention,
the body
temperature
of the
patient
decreases
from 38. 4C
to 37. 6C.
Goal met
Long term goal:
At the end
of the shift,
the patients
results from
the previous
lab test has
slightly
decreased
as displayed
in the
following
values:
CBC (9/23/16)
WBC: 18.2
Segmenter
s: 0.85
Lymphocyt
es: 0.12
Goal not met,

endorse
results to the
next nurse on
duty.
Subjective:
Sa pagkakaalam
ko, noong
nagpacheck up
siya sa health
center dahil
sumasakit pantog
nya habang umiihi
eh nasabihan siya
na may Acute
Kidney Failure, as
verbalized by the
patients son
Objective:
GCS 3-4
(E1V1M1-2)
on IJ insertion
on PNSS 1L
KVO
on Foley
catheter
Urinalysis
(9/20/16)
Urea Nitrogen:
17.04
mmol/L
Sodium: 130
mmol/L

Urinary
Incontinence
related to
degenerative
changes in
the kidney as
evidenced by
the laboratory
results of the:
Urea
Nitrogen:
17.04
mmol/L
Sodium:
130
mmol/L
Potassium
: 2.90
mmol/L
Creatinine
: 570.62
mmol

Short term goal:

After 3 hours of
nursing
intervention, the
patient will be
able to manage
the
manifestation of
the condition
Long term goal:
After 3 days of
the nursing
process, the
results from the
previous lab
tests will
decrease within
normal limits as
displayed in the
following normal
values:
Urea
Nitrogen:
2.85-7.20
mmol/L
Sodium:
136-145
mmol/L
Potassium:

Independent:
Monitor I & O
hourly
Provide catheter
care
Dependent:
Hook patient on
on PNSS 1L KVO
as ordered

Administer
Mannitol 100 cc
IV every 6 hours

Collaborative:
Refer patient for
hemodialysis
with attached
consent and
instructions:

To assess
trends in I & O
for baseline
data
To prevent the
spread of
infection
Increased
circulating fluid
maintains fluid
perfusion and
flushes
sediments and
bacteria
Used for the
promotion of
diuresis before
irreversible
renal failure
becomes
established.
Dialysis is used
to perform the
function of the
kidneys.

Short term
goal:
After 3 hours of
nursing
intervention,
the patient will
be able to
manage the
manifestation
of the
condition.
Goal met
Long term goal:
After 3 days of
the nursing
process, the
results from the
previous lab
tests partially
decreases
within normal
limits as
displayed in the
following
values:
As of 9/23/16
Urea
Nitrogen:

 Potassium:
2.90 mmol/L
Creatinine:
570.62
mmol/L
Lipid Profile
(9/18/2016)
Fasting
Glucose:
152.73
mg/dL

3.6-5.1
mmol/L
Creatinine:
53-97 mmol

NaHCO3

D5W to run for

12 hours

Dialysis is a
treatment that
filters and
purifies the
blood using a
machine.
Indicated in
the treatment
of metabolic
acidosis which
may occur in
severe renal
disease,
uncontrolled
diabetes
Means of
maintaining
tissue
hydration and
a means of
parenteral
nutrition.

10.50
mmol/L
Sodium:
140 mmol/L
Potassium:
4.2 mmol/L
Creatinine:
305.9
mmol
Goal partially
met, endorse
results to the
next nurse on
duty.

Potential Threats
Assessment
Subjective:
none
Objective:

Diagnosis
Risk for injury
related to
decreased
level of

Planning
Short term goal:
At the 15
minutes of
nursing

Intervention
Independent:
Ensure that
side rails are
padded and

Rationale

To prevent
occurrence of
injury due to fall

Evaluation
After 15
minutes of
nursing
interventions,

GCS 3-4
(E1V1M1-2)
with 2 IV lines
attached on
both arms
on NGT
on cardiac
monitor
on NaHCO3
drip
on Foley
catheter

Subjective:
none
Objective:
GCS 3-4
(E1V1M1-2)
on NGT

consciousness

interventions,
the patient
will be
protected
from possible
injuries.
Long term goal:
At the end of
the shift, the
patient will be
free from
injury

Risk for
Impaired Skin
Integrity
related to
prolonged
immobility

Short term goal:

At the end of
the shift, the
nurse on duty
will ensure
the patient
will have
reduced risk
of further
impairment of
skin integrity.
Long term goal:
After 3-4 days
of nursing
interventions,

kept in
raised
Provide
privacy for
the patient
Check the
attached
contraptions
regularly

Dependent
Educate
significant
others about
basic safety
measures
inside the
ICU
Independent:
Change
patients
position
every 2
hours
Provide
regular
morning care

Use
indwelling
catheter
Apply strict
skin care
Provide

To ensure the
patients dignity
To ensure the
patients safety

Negligence on
the safety
measures can
increase the risk
for injury

To reduce
likelihood of
progression to
skin breakdown

To reduce the
proliferation of
infection.
To prevent
possible spread of
infection
To prevent skin
breakdown
To alter excessive
tissue pressure

the patient is
protected from
possible
injuries.
Goal met
Long term
goal:
At the end of
the shift, the
patient will be
free from injury.
Goal met

Short term
goal:
At the end of
the shift, the
nurse on duty
ensures the
patient will
have reduced
risk of further
impairment of
skin integrity.
Goal met
Long term
goal:
After 3-4 days

the patient
will maintain
skin integrity
despite to
prolonged
immobility.

protection by
use of pads,
pillows, etc.
Keep clothes
dry and keep
bed free of
wrinkles and
crumbs
Massage
bony
prominences
gently

Dependent /
Collaborative:
Start OF of
1,500
kcal/day as
per
dietitians
advice
Administer
the following
medications:
Ketoanalogu
es 2 tabs
TID

To eliminate
excessive tissue
pressure

To avoid friction
and promote
comfortability

To prevent
malnutrition and
delayed healing

Prevention and
treatment of
conditions caused
by modified or
insufficient
protein
metabolism in
chronic renal
failure.
Preventing or
treating low blood
potassium levels
when the amount
of potassium in
the diet is
inadequate.

Potassium
Chloride 2
tabs TID

of nursing
interventions,
the patient
maintains skin
integrity
despite to
prolonged
immobility.
Goal met