Sample Care Plan Template Page 33
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51altered circulation, altered metabolic state,
mechanical factors, moisture, AEB patient
on bedrest, diagnosed with malnutrition,
position immobility, use of 2-points
restraints, and Braden scale score of 9.
Key Problem: Impaired
spontaneous ventilation R/T
Key Problem: Decreased cardiac
metabolic factors, 2/2 aspiration,
Supporting Data: Braden scale score of 9;
output R/T altered heart rate and
Key Problem: Risk for aspiration R/T
2/2 encephalopathy and right lower
the patient is on bedrest and mechanically
altered heart rhythm AEB patient
depressed cough, tube feedings, presence of
lobe airspace opacities AEB
ventilated; patient has been diagnosed with
on Levophed due to cardiogenic
endotracheal tube, decreased gastrointestinal
patient ventilated (settings: TV-
malnutrition and has nutritional deficiencies
shock caused by sedation
motility, reduced level of consciousness AEB
400, R-14, Mode-PRVC, FIO2-40,
related to his alcohol dependency; patient
medication, bradycardia, ECG
patient intubated and on ventilator, NG tube
& PEEP-5), spike in BP above 200
has 2 soft mechanical restraints bilaterally
changes with PVC/PAC,
placed with tube feeds, previous incident of
systolic and 100 diastolic with
on upper extremities because of his AWS
abnormal atrial blood gases
aspiration, heavy alcohol consumption,
PVC/PAC ECG changes during
agitation where he was pulling out lines.
values of 7.369, 101.7 (H), 57.8
decreased LOC while sedated with
sedation vacation, ABG values of
(H), 32.6 (H), 6.2, & 97.4, BP
medication, and RASS of 2+ while on
7.369, 101.7 (H), 57.8 (H), 32.6
118/56 on Levophed, suspected
sedation vacation.
(H), 6.2, & 97.4 and lactic acid of
alcoholic cardiomyopathy
3.8, as well as shallow and
pending doctor interpretation of
diminished BS bilaterally in the
Supporting Data: the patient has medical
echocardiogram.
bases.
diagnoses of GERD, aspiration pneumonia,
malnutrition, and alcoholic gastritis; patient
Supporting Data: The patient
Supporting Data: Patient sedation
had multiple risk factors including depressed
was placed on the conscious
vacation trial at the start of shift
cough because intubated, tube feedings,
sedation medication Propofol
was not successful the patient was
reduced LOC related to AWS, heavy alcohol
while he was intubated due to
not hemodynamically stable off of
consumption prior to hospitalization
acute respiratory failure caused
sedation medication with spike in
by AWS. The medication put the
BP and ECG changes to
Key Problem: Risk for infection
patient into cardiogenic shock
tachycardia with PVC/PAC;
R/T malnutrition, decreased
with diastolic below 90, weak
patient ventilated with above
hemoglobin, decrease in ciliary
pulse, and ECG changes. The
settings; patient has diagnosis of
action, increased environmental
patient had to be put on
aspiration pneumonia on day 6
exposure to pathogens AEB
Levophed to manage BP. He is
antibiotic regime with Zosyn, 2/19
increased temperature of 100.4, H &
on a continuous drip for as long
ABG values are: ABG values of
H of 9.0 & 27.9, nutritional
as he is on the sedation
7.369, 101.7 (H), 57.8 (H), 32.6
deficiencies of folic acid &
medication.
(H), 6.2, & 97.4.
thiamine, ventilated, recovering for
pneumonia, and invasive medical
lines (A-line, foley catheter, CVP,
NG tube).
Page 33
Supporting Data: Fever of 100.4;
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
H & H for 9.0 & 27.9; patient was
diagnosed with malnutrition and has
nutritional deficiencies related to his
alcohol dependency; patient has
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