Sample Care Plan Template (Page 36 of 51) in pdf

Nursing Diagnosis and Priority # 1

Impaired spontaneous ventilation R/T metabolic factors, 2/2 aspiration, 2/2 encephalopathy and right lower lobe airspace opacities

AEB patient ventilated (settings: TV-400, R-14, Mode-PRVC, FIO2-40, & PEEP-5), spike in BP above 200 systolic and 100 diastolic

with PVC/PAC ECG changes during sedation vacation, ABG values of 7.369, 101.7 (H), 57.8 (H), 32.6 (H), 6.2, & 97.4 and lactic

acid of 3.8, as well as shallow and diminished BS bilaterally in the bases.

General Goal:

Patient recovers and maintains a normal homeostasis for the remainder of shift after adverse hemodynamic episode that occurred

during sedation vacation.

Outcome Objective(s): (use SMART format)

1. The patient will maintain arterial blood gases within the following safe parameters a pH between 7.35 - 7.45, paco2 of 35-45 mm

Hg, hco3 of 22 to 26 mEq/liter, pao2 of 80 to 100 mm Hg, sao2 of 95% to 100%, and base excess of -5 to +3 during the nursing shift.

2. The patient’s airway will be effectively maintained during the nursing shift. The patient maintaining an sp02 above 95% will

measure an effect airway.

3. The nurse will aid the patient in effectively mobilizing secretions by performing inline suctioning as needed during the nursing

shift. The measurement of effective secretion mobilization is that the patient will not have adventitious lung sounds on auscultation.

Patient Responses

Interventions with time frames/frequency

Rationale (for each intervention)

(subjective/objective data)

1) Monitor the patient q2hrs for signs of

1) All of these assessment factors are signs

1) During the nursing shift the

increased respiratory rate, use of accessory

that the patient might not be tolerating the

patients respiratory status was

muscles, intercostal muscles retraction, flaring of

current ventilation settings and he could be

monitored for these signs q2hrs.

nostrils, and decreased 0

saturation (Ackley &

experiencing respiratory failure (Burns,

The patient did not experience any

Ladwig, 2011).

2005).

of this signs so his ventilation

settings are adequate and he is

tolerating the ventilator.

2) Administer analgesics and sedatives as needed

2) Studies have shown that when nurses

2) During the nursing shift (outside

of the patient’s adverse

to keep the patient comfortable while recovering

have a sedation protocol that allows them to

manage the patient’s analgesics and

from AWS (Ackley & Ladwig, 2011). Titrate up

hemodynamic reaction to his

and down within protocols to maintain

sedatives there is a decrease in the days of

sedation vacation) the patient

hemodynamics at stated parameters.

intubation and hospital stay (Brook et al.,

maintained his hemodynamic status

1999).

within stated parameters-systolic

F:\group\MEPN\MEPN Level III\NURS610B\2013NURS 610B\610BCarePlan

12/17/2012

page 16

Sample Care Plan Template Page 36

Related Articles

Related forms

Related Categories