Sample Care Plan Template Page 32

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MIND MAP (PER LEVEL)
Reason for needing health care/ Medical Diagnosis:
Alcohol Withdrawal Syndrome complicated by aspiration
pneumonitis, acute respiratory failure, hypokalemia,
hypomagnesaemia, hypotension from sedation medication
requiring vasopressors, macrocytic anemia, and
thrombocytopenia.
Anticipated assessments (prep): Neurological, A&O,
PERRL, EOM, Intake & Output, respiratory, pancultures,
Line assessment (A-Line & Central), Restraints, Labs,
Sedation Vacation, medication review patient on Levophed,
review vent settings, ECG review & foley catheter
Assessment Data (concept map): acute respiratory failure
on ventilator, recovering from aspiration pneumonia day 6
antibiotic regime; restraints still needed because patient still
agitated, sedated, and ventilated; Patient still needs Levophed
because pressures bottom out while on sedation medication
and he was not hemodynamically stable enough during
sedation vacation at start of shift to stop sedation medication.
CV: RRR, no murmurs;
Eyes: PERRL, EOM;
Head: normocephalic, atraumatic;
ENT: MMM, thin clear secretions, 7.5 cm ETT secured at 22
cm at teeth;
GI: non-tender, non-distended, not tympanic, no BM for 2
days; GU: foley catheter in place putting out 32 to 175 ml/hr;
MS: moves extremities spontaneously patient under sedation;
Skin: warm, dry, no rashes;
Neuro: RASS score 2+ when put on a sedation vacation;
unable to fully assess LOC because patient is sedated and
ventilated
Page 32
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012

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