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Kelsi Bostic

on 3 May 2013

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Transcript of ICU CARE PLAN

Assessment 84 year old male, at end stage heart failure with no known allergies and a DNR code. Pt has EF rate of less than 10%, the defibrillator has been turned off. CHF and kidney failure is at end stage. Plan is to send patient to pass in comfort of his own home. Review of Systems Skin: Pt skin was moist, cold to touch. Cap refill was 4 seconds on nails and toenails. Pt had skin tear on left anterior forearm, pt ripped off band-aid and began to bleed, was replaced with larger band-aid. Pt skin was dry, dusky, and cool to touch. No signs of pressure sores.
HEENT: Pt normally wears glasses for reading. Pt is balding and ears are dry and unclean. Pupils had slow and little response to pen light. Otherwise eye opening was spontaneous.
Cardiovascular: Bilateral pulses are equal and 2+ carotid,radial, femoral. Auscultation S1 and S2 sounds no gallop, murmur heard in S2, and no adventitious sounds present. HR regular 84 bpm. Blood pressure low 72/47. Leads were taken off of pt preparing for discharge , no ECG rhythm strip. Edema in lower legs and hands, non pitting 2+
Hematology: N/A
Respiratory: Pt uses a NC at night running at 3L. Lungs clear in all bases except, RLL base lung sounds diminished. Breathing easy non labored. 26 Respiration's per minute. Pulse ox 95%. Ratio 1 to 2. SOB with activity re leaved with rest. Trachea is mid-line no deviation. Lung expansion is equal.
GI: Pt has no medical GI issues. Regular diet. Abdomen soft in all quadrants. Bowel sounds are normal active. Last BM 72 hours. Had liquid stool before discharge, had to use enema.
Hepatic: N/A
Renal: End stage renal failure. Foley urinary catheter 16F, Output 1500 mL. Amber colored urine foul smelling. Catheter removed some blood return and discharge.
Endocrine: N/A
Musculoskeletal: Pt has soreness in left foot. Pt uses wheelchair and walker when needed.
Neuro: Pt explains that sometimes he suffers from anxiety. Also that he is forgetful at times. Pt was aware of who he was, where he was, and the reason for being there. Pt had no numbness and GCS had no deductions. Pupils were spontaneous and pinpoint with no response to pin light. Grip was strong and equal. No drooping of the face. No altered sensation in hands and feet.
Psychiatric: Pt has some anxiety. No other psychiatric issues.
Reproductive: Pt is not currently sexually active. Has an enlarged prostate. Background HX JC
Lives at home with care from daughter and wife
Integrity vs Despair Stage of Life
DOB: 07/12/1928
170 pounds
Pt never smoked and rarely drinks
Pt can read but learns better verbally
Pt is alert and very pleasant, great persona Allergies No Known Allergies Past Hospitalizations/Surgeries 2003 and 2006 LHC
2007 CABG, aortic valve replacement- Pocine
2010 pacemaker placed
11/12 and 12/12 for CHF Family History Mother and Father both had heart problems. Immunizations Flu - 2012
Pneumococcal- 2011

No other immunizations charted Medications ordered Aspirin (NSAID) 81 mg qday oral to prevent MI and stroke. Watch for bleeding, stomach pain, hearing loss, NV
Amiodarone (antidysrhymic) 100 mg qday oral for heart. Watch for fatigue, tremor, NV, hypo tension
Coreg (beta blocker)6.25 mg BID oral for CHF. Watch for dizziness, fatigue, hypo tension, diarrhea, NV
Hytrin (alpha adernergic)1 mg qday capsule for HTN. Watch for hypo tension, dizziness, palpitation, lightheaded, edema
Losartan (ARB)25 mg qday oral for HTN. Watch for fatigue, hypoglycemia, chest pain, angioedema
Diuril (thiazide) 250 mg in 9 mL IV push for CHF. Watch for hepatotoxicity, hypo tension, constipation, dizziness
Lasix (loop) 100 mg in D5W 100mL at 10mL/ hr for CHF. Watch for hypokalemia, diarrhea, dizziness, NV
Kdur (potassium)40 mEq qday for low potassium with diuretic. Watch for heart dysrhythmias and palpitations. Vitals: Temperature 97.7 degrees Fahrenheit. 26 Respiration's per minute. O2 sat 95 %. HR 84 bpm. BP 72/47. Pain rated at 8 when walking on swollen foot. Lab Values WBC 4.3
RBC 3.69
MCV 88.6
MCH 27.4
Hgb 10.1
Hct 32.7
His heart issues could be causing his anemia.
Na 142
K 4.2
Glucose 96
Ca 8.5
Cl 107
BUN 70
Cr 3.74
BNP 2642
His BUN and Cr levels could be from the low EF and kidneys not getting any flow. And his end stage renal failure. KEY: Pink font - high lab values Diagnosis Interventions Diagnosis #1 Pt will remain free of side effects from the medications used to achieve adequate cardiac output by end of clinical day.
(Ackley& Ladwig , 2011) Decreased cardiac output r/t altered contractility aeb EF of less than 10%, edema, SOB and fatigue.
(Ackley & Ladwig 2011) Short term goal It is important to watch for the possible s/s of hypotension because then the pt is at risk for passing out and falling. With tremors the gait may be unsteady and cause even more a risk for falling. Same risks for hypotension apply, watch closely no moving about fast. If diarrhea and NV persist then electrolyte imbalance could come into play. Long term goal Pt will demonstrate adequate cardiac output aeb normal blood pressure and heart rate perimeters, peripheral pulse rate, ability to tolerate activity without dyspnea or chest pain by discharge.
(Ackley & Ladwig 2011) Hypo tension is a huge s/s of any drug that helps with BP. Dizziness and lightheaded if they are present keep pt in one position. With edema we do especially do not need the added edema with his CHF issues. With this drug watch the levels to make sure to watch ALTs. Watch for constipation the pt has already been constipated for 2 days. The nurse will monitor and chart blood pressure before and after the medication administration. Between those times monitor every 2 hours. The blood pressure exhibits how well his meds are working and his heart. With his blood pressure make sure it does not go below his normal range because his normal is different. The nurse will monitor and chart pt HR on monitor with rhythm every hour but also every 2 hours go in to room and check pulses manually, check strength and rate. Pt HR is normal so when it gets out of range of 60-90 we want to know so we can alert doctor of his change. If the pulses become non equal and absent this is also an issue. Same apply for rest but as far as angioedema this could interfere with airway so if swelling in the face begins start to monitor the airway closer. Have pt let us know if it becomes difficult for him to breathe. It is important to monitor the pt for these s/s especially because has potential for bleeding and an already open skin tear that was difficult to get to stop bleeding. Fear r/t disease process and dying aeb sad affect from pt and family and current anxiety. Diagnosis #2 Short term goal Pt will understand his current health prognosis and be comfortable with where he is in his life aeb stating medical issues and his plan by the end of clinical day. Doing this can alleviate the stress and anxiety he already has so that the next task of understanding prognosis can be done easier. The nurse will explain that the normal EF is much more that 10% maybe explain with a water hose. Then go on to explain CHF and the swelling in legs that his kidneys are not helping because they are low functioning and can't release as much fluid. But also explain that his blood pressure is much lower than where it should be. He needs to understand this so make sure he is intently listening and can relate to it. The nurse will plan to have an animal come and visit in the garden area. Having animal encounters can raise a persons attitude. Having the pet come in would raise his spirits and it helps reduce fear in older patients. The nurse will stay with the pt to talk about his fear and to explain more questions he has. Also be sure to just communicate with him and his family. Talking and being with the pt is huge. The doctor leaves but nurses stay by their side and explain what they don't understand and that in itself can lower fear. Pt is tired and SOB with little activity. With the EF of less than 10% it would only seem fit that this is the primary diagnosis. It is important that he does not have s/s from the meds he is on to manage his heart problems, because s/s could prevent his compliance even though it was not an issue before. The medications are very important. Pt prognosis is not good but I feel that he has not realized that so it is important that he is comfortable with it. Being able to understand what is happening to his body is important and will help with his fear. The nurse will provide the pt a safe environment and have same people take care of this pt. Also keep the information given the same to avoid confusion. Keeping the place safe and having the same people take care of him will make him feel safe and understand easier. Long term goal Pt will accept their prognosis aeb good coping skills and ability to help plan for funeral by discharge. The nurse will explore what coping has worked for the pt in the past with other trying times. If they worked try to incorporate if not we can make new ones. Exp: talking to family members in a group or one on one, doing arts and crafts, reading the paper, or journal writing Coping skills are neccessary when accepting that something is going to happen you do have to cope with it whether it is what you want or what others want so having him have the ability to cope is huge. The nurse will assess what pt biggest concern about death is? Does he want spiritual consult? Do you think that your family will be ok once you are gone ? Discussing that fear is the way to accept it and also knowing that everyone else will be ok will help with accepting what is going to happen also. The nurse will slightly discuss possible funeral plan, burial site? Ask if he had thought about any of this? Planning these can help with this seeming real to him and that it is going to happen sometime so we want to do this and be prepared. Kelsi Bostic
ICU Care Plan Chief Complaint Pt was admitted from outpatient clinic. Was to receive infusion for CHF but his CHF was bad and they decided to admit him. Also has ischemic cardiomyopathy.

Pathophysiology- The ability for your heart to pump blood has decreased because the main part of your heart is dilated. Evaluation #1 The short term goal I believe was met. Even though my pt had some constipation issues I think it was brought on by frequent enema use. To relieve his constipation we brought him an enema and it was alleviated. Pt also had edema but this was more that likely a normal issue with CHF. His potassium levels were maintained by a dose of K-dur and he did not experience the s/s. He also understood the reasons for taking the meds and was very compliant.

The long term goal was actually available to be evaluated because he was discharged and sent home. From the morning to afternoon his HR, BP, and pulse strengths remained same. He was able to walk around the unit varies times but still presented SOB which was managed with breaks. I think because his prognosis is so bad that it would take more extreme measures and may be irreversible. Evaluation #2 The short term goal was met. He understood that he had been fighting it off for a long time. He was also very interested to what I had to say about his disease process. I think that his family defiantly understands because they have the DNR order and have turned off his pacemaker.

The long term goal was not met. Most of the time was spent helping him try to urinate and him resting because he was fatigued. Then once family was there it was an awkward scene. Not much talking and such. So the interventions were not implemented. More time would have helped. Summary I think that this pt needs some more education still. I think that he still did not fully understand all of his medical issues and as a nurse I want them to be fully knowledgeable on their disease process. He was a very plesant pt and I think that I prioritized his dx for what I think is important and relevant. I would think that this was an excellant care plan for him and maybe for a 4th dx use non compliance because the whole enema situation. Lasix watch for hypokalemia, diarrhea, dizziness, NV , hearing loss Aspirin watch for bleeding, stomach pain, hearing loss, NV, heartburn Amiodarone watch for fatigue, tremor, NV, hypo tension (dizziness, weakness, faintness, loss of color ) Coreg watch for dizziness, fatigue, hypo tension, diarrhea, NV
Hytrin watch for hypo tension, dizziness, palpitation, lightheaded, edema. Losartan watch for fatigue, hypoglycemia, chest pain, angioedema Diuril watch for hepatotoxicity, hypo tension, constipation, dizziness Kdur watch for heart dysrhythmias and palpitations. Lasix wastes potassium so the labs should be watch closely.He was ordered a dose of K to balance it out already. The hearing loss could happen if the infusion occurs too rapidly. K can cause abnormal heart rhythms so watch the strips, and ask him to report any palpitations because messing with the heart is very critical. The nurse will monitor and chart his activities. Is the pt SOB when he... moves in bed, eats, talks, sits up, moves from bed to chair? If so lets teach him just do in breaks and keep your head up and take a deep breath. SOB during activities then he might need to wear oxygen more than just to bed. Monitoring this would let us see if his heart will pump more blood. Also: Evaluation and Summary Basic info and goals The nurse will provide backrubs and massages to pt to decrease the anxiety that he already has. Skin- none reported
HEENT- Glasses to read. Hard hearing.
Cardiovascular- Chest pain. Pacemaker. HTN. MI. Pocine aortic valve. SOB. Edema in legs.
Hematology- none reported
Respiratory- oxygen use at night 3L
GI- last BM 72 hours ago. Hernia as a child.
Renal- end stage renal
Reproductive- none reported
Safety- up with assist, PT uses walker. Recent fall at home 6 weeks ago. Diagnosis #3 Risk for falls r/t medication treatment and left foot pain aeb difficulty rising from bed and chairs and limping on left foot. Also aeb the attempt to have a BM put him at risk for vagal drop. Short term goal Long term goal Pt will remain free of falls aeb no falls by the end of the clinical day. Pt will learn and explain methods to prevent falls and injuries aeb pt stating ways to do so before the pt is discharged. The nurse will assess when the patient is most at risk by doing various skills. Like just walking, then carrying food and then drinks, then carrying some clothes. By assessing this we know and can help pt realize what tasks he needs help with and some ways to do that. The nurse will teach the pt when getting up make such the wheelchair is locked, that whatever he is getting up from is stable and when that is complete sit up for at least 30 seconds and let feet dangle to prevent orthostatic hypotension
(basically dizziness) If the chair is unstable this adds more of a risk to fall so teaching this can eliminate that risk. Also teaching about orthostatic hypotension will prevent falling also possibly. The nurse will show client his call light for the duration of the days use. But also recommend that his wife get him a bell or phone that he can ring for assistance getting up. Assistance is a big key. If he is unstable someone else can steady him and help him out. The nurse will recommend taking some pain medicine for the foot pain an hour before perceived activity. Also taking stool softeners instead of enemas and if does not help then use both. Don't strain By having pain under control pt can focus more on walking and have a lesser chance of falling. Also the BM straining could cause BP drop and him to pass out. The nurse will suggest pt to wear non slip socks to prevent from slipping, and always use a cane or walker. Using assistant devices work to prevent falling when used properly. The nurse will suggest to pt to eat a well balanced diet to help the skeletal system get stronger and well balanced. Eating a good diet will help with balance and create strong bones to help with stability. The nurse will educate the family on the surroundings that could enable him to fall such and extension cords, loose mats, bright glaring lights, no lighting, slippery shoes, and shoes that just slip on are all big DONTS. It is important for family to check for these things to see if they are present in the home. If these are avoided then the risk of falling can be reduced. With the medication the pt is on causing dizziness and hypotension falling is always a big risk. With the leg pain and the history of falls concludes that it is an important dx. Evaluation #3 The short term goal was met. The pt did not fall during the clinical day. Pt used his call light each time he wanted to get up out of bed. When he would get up he would sit for 30 seconds dangling feet then attempt to stand up. He did not have pain medicine ordered so each time he walked his foot really bothered him and you could notice that each time that he did so.

The long term goal was met. The pt realized what he should do to prevent falls. He took two pairs of the hospital socks home with him. And he stated that they had a bell sitting around somewhere that they would locate. His wife and daughter stated that they would look over the house and make sure these issues were alleviated. If nurse notices that pt becomes SOB and O2 Sat drops below 90% administer O2 nasal canula. It is important that pt is well oxygenated to help with cardiac output. The nurse will administer meds at correct dosage times and watch for s/s for each drug as listed in other interventions Most important ones to watch for is the bleeding with aspirin since he did have trouble stopping the bleeding on his skin tear. Hypotension since he is already so low watch for symptoms- dizzy and pale. And last the electrolyte imbalance with diuretics- heart palpitations, dys. This goal fits with dx and is a better one for long term because would take longer to achieve. By monitoring we can determine if the pt output is normal. Accepting the prognosis is important but having coping skills to do so is even better. Having this as a goal will help with his fear. It is important that the pt remains free from falls during the clinical day especially on our watch but also until discharge also. Having the pt know what can prevent falls eliminates half the risk. If they are aware and others can reduce other risks it will be safe for the pt. Ackley & Ladwig, 2011
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