Sample Care Plan Template Page 34
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51PROBLEM LIST (PER LEVEL)
PROBLEM
Nursing Diagnosis with R/T and AEB
(Number problems in order of priority)
(Number diagnoses in order of priority)
1) Patient is sedated and ventilated while going
1) Impaired spontaneous ventilation R/T metabolic
through alcohol withdrawal syndrome because of
factors, 2/2 aspiration, 2/2 encephalopathy and right
episode of acute respiratory failure caused by
lower lobe airspace opacities AEB patient ventilated
aspiration pneumonia and diminished LOC due to
(settings: TV-400, R-14, Mode-PRVC, FIO2-40, &
encephalopathy that made him unable to protect his
PEEP-5), spike in BP above 200 systolic and 100
airway. The patient is on day 5 of ventilation and the
diastolic with PVC/PAC ECG changes during
priority nursing action at the start of shift is to initiate
sedation vacation, ABG values of 7.369, 101.7 (H),
a sedation vacation to see if the patient might tolerate
57.8 (H), 32.6 (H), 6.2, & 97.4 and lactic acid of 3.8,
weaning and if acute encephalopathy caused by
as well as shallow and diminished BS bilaterally in
AWS is resolved.
the bases.
2) The patient was placed on the conscious sedation
2) Decreased cardiac output R/T altered heart rate
medication Propofol while he was intubated. The
and altered heart rhythm AEB patient on Levophed
medication put the patient into cardiogenic shock
due to cardiogenic shock caused by sedation
with diastolic below 90, weak pulse, and ECG
medication, bradycardia, ECG changes with
changes. The patient had to be put on Levophed to
PVC/PAC, abnormal atrial blood gases values of
manage BP. He is on a continuous drip for as long as
7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4, BP
he is on the sedation medication. So the second
118/56 on Levophed, suspected alcoholic
priority problem for this patient is monitoring of the
cardiomyopathy pending doctor interpretation of
patients Levophed continuous drip and titrating drip
echocardiogram.
so that patient maintains a BP systolic 80-100 or 30-
40 mm Hg below previous systolic.
3) The next priority of care for the patient during this
3) Risk for infection R/T malnutrition, decreased
shift was risk for infection. The patient had an
hemoglobin, decrease in ciliary action, increased
elevated temperature of 100.4 through the night and
environmental exposure to pathogens AEB increased
into the day shift. The source of the fever could not
temperature of 100.4, H & H of 9.0 & 27.9,
be determined so we notified the doctors who
nutritional deficiencies of folic acid & thiamine,
ordered pancultures be performed on all of patient
ventilated, recovering for pneumonia, and invasive
invasive lines (A-line, foley, and CVP).
medical lines (A-line, foley catheter, CVP).
4) The patient has multiple risk factors for aspiration
4) Risk for aspiration R/T depressed cough, tube
including being less alert due to his sedation
feedings, presence of endotracheal tube, decreased
medications, GERD, drinks large amount of alcohol,
gastrointestinal motility, reduced level of
and previous incident of aspiration causing
consciousness AEB patient intubated and on
pneumonia. The patient also is intubated and on tube
ventilator, NG tube placed with tube feeds, previous
feeding.
incident of aspiration, heavy alcohol consumption,
decreased LOC while sedated with medication,
medical diagnosis of GERD and RASS of 2+ while
on sedation vacation.
F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan
12/17/2012
page 14
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