Sample Care Plan Template Page 11
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51syndrome, agitation/pulling out lines, and RASS score of 2+ when off of sedation. The patient is
a fall risk and has bed down and 2x side rails up as safety measures.
Fall risk score: High
Tool used: MIHS Standardized tool
Sleep-Rest Pattern:
Assess sleep habits, disturbances, and alterations.
The patient is currently sedated except for sedation vacation trials. During the sedation
vacation trials, the patient is agitated and disturbed. Prior to hospitalization, the patient admitted
to being depressed because of his wives passing and that he had been having difficulty sleeping.
Also, prior to his intubation and sedation for his alcohol withdrawal syndrome the patient was
restless and agitated.
Cognitive-Perceptual Pattern:
Assess LOC, GCS, neurological status/alterations (speech, hearing, vision, PERRLA, motor, and
sensation).
The patient’s LOC is sedation so he is unresponsive to commands. When the patient has
a sedation vacation he is not alert and unable to respond to commands due to his alcohol-induced
encephalopathy. The patient’s RASS score off of sedation is 2+. The patient while sedated is
unable to speak but prior to intubation he was coherent, verbal, and had no difficulty with
hearing. His pupils are 2mm and are PERRL. His calculated GCS score for the day of care was
7. His motor responses are diminished while on sedation, but he has movement to painful
stimulus on all for extremities. The patient also has spontaneous movement of all extremities.
Respiratory System
Breathing Pattern (e.g. depth, rate, rhythm, use of accessory muscles):
The patient is intubated and on a ventilator. His breaths are shallow, regular, and the vent
is set at a respiratory rate of 14. Upon assessment there are not obvious signs of accessory
muscle use.
Breath Sounds (e.g. clear, course, wheezes, location, etc.):
The patient’s breath sounds are shallow and diminished bilaterally in the bases.
Describe any Cyanosis (e.g. location, severity):
No signs of cyanosis are present and the patient’s capillary refill is less than 2 seconds.
Cough (e.g. productive, nonproductive):
The patient has an endotracheal tube in place. He has no obvious signs of a cough.
Sputum (e.g. color, amount, consistency, odor, how obtained):
The patient has a scant to moderate about of sputum that is clear, white, and thin that was
obtained from inline suctioning.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan/12/17/2012
Page 11
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