Sepsis Care Plan Adult Health

Care Plan Paperwork Medication Documentation Example: Generic Name: Digoxin Trade Name: Lanoxin Pharmacological Classification: Cardiac glycoside Therapeutic Classification: Antiarrhythmic, cardiotonic Dosage Recommended: Usual dose: 1. Calculate dose based on lean body weight (LBW), CrCl (creatinine clearance), age, as well as concomitant disease states, concurrent medication, and other factors that may alter the effects of digoxin. 2. Adult dose: Loading dose: 0.4-0.6. mg IV or 0.5-0.75 mg PO; Maintenance dose based on serum digoxin level. Routes of Medication: IV, PO Is Dosage and Route Ordered Safe? X Yes  No Mechanism of action: Include how drug is excreted: 1. Increases the force of contraction of the cardiac muscle (myocardium); when the force of contraction of the myocardial increases, the amount of blood leaving the left ventricle of the heart at the time of each contraction or cardiac output is increased. 2. Results are a slower, stronger beat with  cardiac output. 3. Drug is excreted in the urine. Adverse Reactions/Side Effects (3): Most common 1. Cardiac – Bradycardia; arrhythmias 2. Gastrointestinal – Anorexia, nausea, & vomiting 3. Visual disturbances – Blurred vision, yellow or green vision, halo effect around dark objects) Nursing Implications (3): 1. Check the apical pulse for 1 minute prior to administration of drug, if less than 60 beats/min or greater than 100 beats/min, withhold drug and notify the physician. 2. Monitor the serum potassium level, if less than 3.5 mEq/L, notify the physician of lab value. 3. Observe for signs/symptoms of digoxin toxicity: anorexia, nausea, &/or vomiting. Indication of medication for assigned patient: PO dose order to control ventricular rate in response to persistent A-fib Generic Name: cefazolin Trade Name: ANCEF Pharmacological Classification: cephalosporin Therapeutic Classification: beta- lactam antibiotic Dosage Recommended: Usual dose: Mild Infections: 250-500 mg every 8 hours Moderate-to-Severe Infections: 0.5-1 g every 6-8 hours Life-threatening Infections: 1,000 -1,500 mg every hour Routes of Medication: IV infusion, IVP, IM Is Dosage and Route Ordered Safe?  Yes ** At the dose & rate, only safe when mixed with Dextrose  No Mechanism of action (How does the medication work in the body to cause the effect?): Include how drug is excreted: Inhibits bacterial cell-wall biosynthesis by interfering with peptidoglycan synthesis. Drug excretion is kidneys. Adjust dose for pts with renal impairment. Adverse Reactions/Side Effects (3): (1) GI Upset (2) loss of appetite (3) allergic reaction Nursing Implications (3): (1) With larger doses of Cefazolin, nurse needs to reconstitution cefazolin and administration with dextrose. (2) Closely monitor renal function (BUN & Creatinine) for nephrotoxicity (3) Educate patient that , as with any antibiotic, is very important to take the entire prescription. Standard regimen: 14 days Indication of medication for assigned patient: Cefazolin is used to treat a variety of virulent bacterial infections. The primary indication for this particular RX is to treat Septicemia. A secondary benefit is it also can treat pneumonia the patient has been dx with both infections Trade Name: Heparin Generic Name: heparin sodium Pharmacological Classification: Anticoag Therapeutic Classification: Anticoag Dosage Recommended: Usual dose: Unit-dose vials: 1,000 units/mL; 5,000 units/mL; 7,500 units/mL; 10,000 units/mL; 20,000 units/mL Routes of Medication: IV; SQ Is Dosage and Route Ordered Safe?  Yes  No Mechanism of action (How does the medication work in the body to cause the effect?): Include how drug is excreted: Accelerates formation of antithrombin III–thrombin complex and deactivates thrombin, preventing conversion of fibrinogen to fibrin Adverse Reactions/Side Effects (3): Most common 1. Hemorrhage 2. Thrombocytopenia,3. hyperkalemia Nursing Implications (3):1. Elderly patients should usually start at lower dosage. 2. Monitor patients for hyperkalemia during therapy. 3. Monitor patient for signs of bleeding. Indication of medication for assigned patient: DVT, PE, Thrombopenia NURSING PROCESS WORKSHEET – CONTINUED NURSING NOTES The content which follows, requires a research component to ensure an adequate assessment, to include peer reviewed articles, research data bases, etc. All information must relate to your patient during this admission and references need to be listed. NURSING PROCESS WORKSHEET – CONTINUED NURSING NOTES The content which follows, requires a research component to ensure an adequate assessment, to include peer reviewed articles, research data bases, etc. All information must relate to your patient during this admission and references need to be listed. 1. Based on the collected data, identify the client’s primary pathophysiology [related to primary diagnosis] for this admission. Septicemia or sepsis occurs when a localized infection becomes systemic. Sepsis is essentially blood poisoning and commonly cause by Staphylococcus aureus , Escherichia coli, and some types of streptococcus. The most common infection associated with development of sepsis is pneumonia (Patient’s initial diagnosis) and patients with chronic diseases, such as cancer and lung disease (Patient had both), are at the greatest risk for developing sepsis. The pathophysiology of septicemia is extremely complex and multifactorial. The immune system is usually pretty effective at fight off infection, but for severe infections in at -risk patients can cause a system overload. It is the cytokines that initiation the exaggerated inflammatory response, leading to a compromise of vascularity. AS a result of vascular changes the bacteria are able to enter the blood system and spreads systemically. Sepsis quickly turns deadly if the patient develops septic shock (Stearns-Kurosawa et al. 2011). 1. How does the client’s past medical and social history contribute to the primary admitting medical diagnosis? The patient has a hx of metastatic laryngeal cancer. S/P laryngectomy and surgical placement of tracheotomy. Patient recently withdrew from palliative chemo therapy and developed a case of pneumonia. His primary care provider Rx Abx in which the patient did not take any. Patient presented in the ED one week after onset of pneumonia symptoms/dx severely hypotensive, malnourished, SOB, and his trach was expelling copious amounts of thick purulent mucus. Sepsis protocol was initiated and was later dx with septicemia, then later septic shock. The septicemia likely originated due to the untreated pneumonia, which exacerbated the lung and pharynx cancer( with Mets also in spinal column). Because of his trach, his airway is already compromised, which didn’t help maters. With the additional, WBC activity and activation of the complement system, and the infection is becoming increasingly virulent due to noncompliance of previous Rx of ABX therapy, the cytokines inevitably sound the alarm for systemic inflammatory response. This overreaction by white bold cells that triggered snowball to septic shock was the initial diagnosis of cancer, followed by the surgery to remove it in the larynx and insertion the permanent trach, in conjunction with the chemotherapy treat the patient was having, his white counts were already compromised as was his nutrition. Adding the dx of pneumonia itself probably did cause the exacerbation, rather it was the pneumonia that was allowed to worst trough non treatment. The lungs were completely under attack and cancer treatment had crippled his immune system. It was kind of a perfect storm of sorts. 2. How do the client’s co-morbidities and medical history impact the treatment and recovery? The patient has been diagnosed with neck, throat, lung, and bone cancer, He still is a heavy smoker according to his charter. The cancer has caused his WBC to 3. If identified, how does the interventional procedures/surgical interventions impact the client’s recovery? The trach suctioning opened his airway allowing for ventilation and respiration, allowing oxygenation of the entire body. PEG allowed him to receive nutrients. The patient refused several of his interventions and treatments intermittently through out the day. However, at the very least, the trach suctioning helped him breath and receive oxygen and trach dressing changed will help prevent further infection getting into the airway. 4. Briefly explain the abnormal lab values [if applicable] as they relate to your client’s pathophysiology and/or history. How were the abnormal values addressed? Across the board the patients WBC, RBC, Hgb, Calcium, and Pre-albumin/albumin were all extremely low. And all of these low lab values steam from one source….Cancer Has the client had any cultures or drug levels obtained during this admission? Yes If yes, what treatment and interventions were implemented as a result of positive cultures or abnormal drug level Positive for Streptococcus & MSSA. ABX therapy for pneumonia. MSSA is ongoing and not treated. 5. Identify at least one teaching need for the client and/or family. If you were able to implement this teaching plan, please explain the impact on the overall plan of care. Importance of maintaining adequate nutrition, especially in time of illness because the nutritional status of the body has a direct correlation to the body’s ability to heal, fight infection, and function at an optimal level. Nutrition=Health The two go hand in hand! 6. Identify the Joint Commission Safety Goal/s that is/are most applicable to your client during this admission. CAREPLAN FORMAT ONE Nursing Diagnosis Per Page –TWO Nursing Diagnosis Due Per CarePlan ASSESSMENT r/t THIS Nursing Diagnosis Subjective: Diarrhea, nausea, vomiting, decreased appetite, refusal of feeding interventions, recent weight loss, lethargic, Objective: BMI 15.44, Pre-albumin & albumin labs low; emaciated, tube feeding through PEG NURSING DIAGNOSIS Imbalanced nutrition: less than body requirements R/T GOAL BROAD GOAL STATMENT Pt will attain nutritional status improving OUTCOMES 1. Pt will participate in nurse-pt education on achieving adequate nutritional intake during morning rounds. 2. Pt will not refuse prescribed feedings q4hr for entire shift (12hrs/3feedings) 3. Pts lab work will show increase in albumin/prealbumin levels by end of shift. PRIORITY NURSING INTERVENTIONS OUTCOME #1 1. Nurse will assess pts knowledge of nutrition. 2. Nurse will educate patient about the close relationship between nutrition and health. 3.Nurse will teach Pt how to monitor nutritional status with a daily dietary input/output log in conjunction with daily weigh OUTCOME #2 1. Nurse will provide education about the prescribed diet. 2. Nurse will refer to dietitian or nutritional support team. RATIONALE 1. Patient education has the potential to have a tremendous impact on health promotion and disease prevention. But first it is important for the nurse to know his/her audience and center the education around his/her individual needs. A very brief interview, just prior to providing the patient education, can establish the patient’s health literacy Therefore, eliminating over/under educating, neither produce the desired effect of pt education. 2. Diabetes Mellitus & CVD are among the most prevalent disease among Americans. Poor nutrition is at the top of the list of modifiable risk-factors for both diseases. Patients need to understand how EVALUATION OUTCOME #1 - Partially met Pt seems very withdrawn and expressed no interest in education of any kind. OUTCOME #2 - Met - Pt has received every ordered feeding. OUTCOME #3 - unmet - Labs have still not returned to a normalized base line. Albumins still low. **Paragraph with overall review and revisions decrease in dietary intake, secondary to Chemotherapy, AEB Body weight 20% or more under ideal for height and frame, decreased subcutaneous fat/muscle mass 3. Nurse will request a consult for the pt with social work, palliative, and chaplain services. OUTCOME #3 1. Nurse will continue to monitor pts labs 2. Nurse will administer antiemetic on a regular schedule before and after administration 3. Nurse will monitor for effectiveness of antiemetic dangerous malnutrition is to the body, especially considering the pt already has a compromised immune and integument system, two of the body systems affecting by inadequate nutrition. immunocompromised and. 3. The most effect way to monitor a pts nutritional status would be serum levels of prealbumin/albumin. However, the patient can keep track of his consumption and daily weights. 1. Talking with the patient about what the prescribed order say, mean, and/or indicate can relieve unnecessary stressed cause by the medical language barrier. If a nurse was to take just a few minutes to remove the jargon and put it into terms non-medical professionals will relate to, does help the patients feel me in control of their own bodies and health care. In this case the patient had a myriad of complications that attributed to his nutritional status. He was severely malnourished and wasting away. His medical Hx is extensive to included cancer, pneumonia, sepsis, As I read and studied his case the more convoluted it became. I was able t0o witness many of the concept taught in lecture unfold in his room. I am grateful for this experience and if I could have changed anything, I would have brought him some water. 2. Collaboration with dietary team members helps provide for specific dietary plan to meet individual needs and reduce problems associated with protein, calorie malnutrition and micronutrient deficiencies. As well as other interventions aimed at improving the pts nutrition. 3. The pt’s poor prognosis may be the underlying causative factor leading to his withdrawal from medical intervention (i.e., tube feedings). It would be in the patient’s best interest to call in the specialist in this area to ensure all of his need are being addressed and met. 1. This will help identify the degree nutrient imbalance and malnutrition and influences choice of dietary interventions. Nurse must monitor albumin closely if it very low due to the chances of causing fluid shifts on prealbumin/albumin, an indication for albumin to be ordered and given to pt. 2. The only nutrients the patient is receiving is through PEG. With Pre-Albumin critically low, any further lose of nutrients via emesis would cause further harm. 3. If the antiemetic doesn’t work pt losses nutrients when vomiting. Ensuing the med is effective is an additional means of ensuring as much nutrients enters and remains in the patient as possible. ASSESSMENT r/t THIS Nursing Diagnosis Subjective: nonproductive cough, fatigue, SOB Objective: Copious purulent secretions & mucus plug in trach cannula, rhonchi present, labored breathing. NURSING GOAL BROAD GOAL STATMENT Pt will experience ease of breathing. OUTCOMES 1. Pt will have a significantly decrease in thick, purulent secretions by end of shift. 2. Pt will maintain a clear and effective PRIORITY NURSING INTERVENTIONS OUTCOME #1 1. Nurse will perform trach suctioning to remove mucus plug and excess thick secretions 2. Nurse will administer and monitor warmed, humidified oxygen via FiO2. 3. Nurse will administer NS 100ml/hr RATIONALE EVALUATION 1. The thick mucus plug lodged in trach cannula is obstructing airway and ventilation. Suctioning the trach will remove excess secretions opening up the airway and increasing oxygen supply to body. 2. Tracheostomy bypass the nares inside the nasal passage, it is here that the air breathed in is OUTCOME #1 - Met - After trach care and suctioning was performed, a new cannula was inserted and the obstructed one removed and degraded. Patient was able to continue to expelling secretion via a productive cough. OUTCOME #2 DIAGNOSIS Ineffective Airway Clearance r/t pneumonia and hx of lung cancer AEB labored breathing with abnormal breath sounds and thick purulent secretions. airway during shift. 3. Pt will have maintain a normal depth and rate of respirations during shift. Continuous IV OUTCOME #2 1. Nurse will monitor effectiveness of cough, observing color and consistency of sputum. 2. Auscultate the lungs, noting areas of decreased ventilation and for the presence of adventitious breath sounds. 3. Nurse will encourage patient to cough and perform deep breathing exercises. OUTCOME #3 1. Nurse will elevated head of bed to help support ventilation 2. Nurse will place patient on continuous Spo2 monitor. < 94% humidified and warmed. Therefore, artificial humidity and warmth must be provided to trach patients. 3. By keeping the patient well hydrated it is anticipated that the thick secretions obstructing the airway will thin out with the extra fluid on board. 1. By monitoring the patients ability to expelled the mucus in the lung by a productive cough, the nurse can ascertain the characteristic of the sputum and assess the patients airway, ensuring it is not occulted. 2. Auscultating the lung field can tell the nurse if the patient is experiencing trouble with ventilation. Any abnormal sound can be cause for concern as it could be the buildup of fluid or thick secretions obstructing airflow. - Met Patient airway remained patent, patient’s cough because a bit strong and more productive. On auscultation the right upper lobe was indicative of rhonchi breath sound, but no evidence of diminished breath sounds or worsening of rhonchi in the right lung. OUTCOME #3 - Met - Pt maintained a respiratory rate WNL; avg 16-18RR, and his work of breath eased and was no longer utilizing use of accessory muscles **Paragraph with overall review and revisions This patient has a hx of metastatic laryngeal cancer. Pt S/P laryngectomy and surgical insertion of permanent tracheostomy. Patient also underwent chemo but recently notify provider. 3. Nurse will request respiratory consult 3. by the nurse continuing to encourage the patient to cough and breathe deeply, EBP states that these actions will help the patient expel all of the mucus/ secretions and allowing for better airflow and gas exchange. 1. First priority with any respiratory patient. Raise the bed help easy work of breathing, slow respirations and increase the airflow into the lungs to be exchanged with CO2 2. The nurse should not wait for the patient to become cyanotic. Cyanosis is a very late sig of hypoxia. While monitoring pt SPO2, it is cost effective, easy to ready, easy to maintain continuously and most important it can immediately can alert the nurse to signs of respiratory distress before damage to tissues has withdrew from palliative oncology treatment. Cancer has now spend to pharynx, lung (primarily right lobe) and spinal column. At this point there wasn’t much we could do to change the inevitable but dto keep him comfortable, but he began to refuse treatments and was completely withdrawn. I tried to make short, light conversion. Due to the trach, he could not speak so I would ask simple yes/no question, just trying to get him to engaged in the outside world, as it was clear he had closed himself off. If there were anything that I could have done differently, I wish I would have had the necessary training/ tools to support him through his grief. I felt completely hopeless to help this patient but wanted so badly to help ease is troubled mind if only for a solitary moment when he laughed at my joke. ***This patient is terminal and very, very sick. In the eight hours of my time with him, I occurred. This early sign give patient a much better prognosis; however, immediately contact physician with SBAR or rapid response as/when indicated. witnessed my patient travel through the 4/5 stages of grief. I saw the 1st stage (denial) within his chart, stages 2-4 (anger, bargaining, depression) I personally witnessed, and it was later brought to my attention that with in the coming day our my time with him he had reached stage 5— Acceptance. As heartbreaking as his story is, I feel incredibly honored to have been able to learn from him and see something not to many can say they have witnessed, much less in one day. I asked for a case that would really make me think and use my critical thinking skilled and this was absolutely the best experience of my entire clinical rotation, I went home thinking about this patient and everything I saw, trying to piece together it he puzzle. I pour over research article after research article and I loved every minute. I have learned so much from this patent and I will never forget his willingness to allow me to care for him, learn from him, and grow. Just something I have need to get off my chest and figured this was the safest, most appropriate places to do it: