Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Patient: 2 Age: 67 Gender: Male

Allergies: Cheese, Tuna, Turkey, Beef, Pork
Code Status: Full resuscitation Wt: 70.1 kg Ht: 163.0 cm
Admit Date:06/11/2017
Past Medical and Surgical History (PMH/PSH):
PMH: Stroke, Diabetes Mellitus, At risk of venous thromboembolism, At risk for falls, Postoperative care, Imbalanced nutrition,
Preoperative care. (Based on MAR)

Social history (ethnicity, occupation, marital status, family support, living situation):
Pakistani; married, male, with 3 children. Pt resides in NW, D.C. His oldest daughter studies at GWU pursuing a degree in IT.
Admitting Diagnosis: Sepsis 2, Urinary Tract Infection, Acute Ischemia, Diabetes Mellitus and Hypertension. (Based on MAR)

Synopsis of Current Hospitalization (timeline): 67 years old male admitted to the hospital, due to Sepsis and UTI infection. Patient
was confused and weak.

Current Medical Diagnosis: Sepsis, UTI infection.

Pathophysiology: Sepsis is a complication of infection and occurs via an immune response to any kind of infection in the blood.
Changes in the endothelial layer of blood vessels are initiated by inflammatory substances 2 ᴼ to the presence of infectious
microorganisms. Cytokines react with the endothelial cells and cause damage which, in turn, causes micro blood vessels to become
leaky. The leaky vessels cause microorganism to spill into surrounding tissues resulting in edema. (McCanace, Huether, 2014)
Signs and Symptoms: Increased heart rate, increased respiratory rate, decreased or increased body temperature, suspected or
confirmed infection. Burning on urination, frequent urination, foul smelling urine, fever and chills, suprapubic tenderness, elevated
with blood cell (WBC) count, hematuria, bacteriuria, low back pain or flank pain, fatigue, anorexia, incontinence (older adult) and
cognitive change (older adult).
Risk Factors: Burning on urination, frequent urination, foul smelling urine, fever and chills, suprapubic tenderness, elevated with
blood cell (WBC) count, hematuria, bacteriuria, low back pain or flank pain, fatigue, anorexia, incontinence (older adult) and cognitive
change (older adult). Chronic diseases (Diabetes Mellitus), elderly individual with weakened immune system, fall risk.
Common Diagnostics: Sepsis. Urinalysis is the key to diagnosing the UTI, presence of RBC and/or WBC in the urine, bacteria in the
urine, urine culture and sensitivity, WBC count.
Nursing Care/Considerations: Patient is at risk of falls. It’s important to lower the bed to floor level for fall prevention. Patient needs
to be repositioned every 2 hours because of risk of pressure ulcers. Patient is urine-incontinent sometimes, but not stools. He needs to
be frequently monitored for urine. Patient needs to have a call bell with hand band at all the time and non-slippery socks to avoid fall
risk.
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Treatments: Care must be prompt. Emergency IV of antibiotics, depending on blood pressure, Vasoconstrictors drugs may be given
intravenously to increase BP. Patient needs to take a lot of fluids to flush the bacteria from his urinary tract. Patient needs to use the
bathroom regularly to avoid reinfection. Use of a catheter to manage the incontinence should be limited, due to the high risk of
infection.

Gulanick, M., Myers, J.L. (2013). Nursing care plans: Diagnoses, interventions, and outcomes. (8th ed.). St. Louis MO: Mosby Elsevier.
McCance, K.L., & Huether, S.E. (2014). Pathophysiology: The biologic basis for disease in adults and children. St. Louis, MO: Elsevier

Relevant Medical ORDERS

VS freq: Q 8H
Diet: Diabetic meal Blood sugar frequency: Before each meal.
Activity: Bed rest.
Oxygen: 2L Nasal Cannula Respiratory Tx: N/A
Dressing Changes: N/A
Other relevant orders: (Such as PT, OT, Speech therapy, falls precautions, circulation or neuro checks, SCD’s, etc.)
Risk for fall and seizure precaution, ulcer precaution and neuro check, risk for venous thromboembolism

Safety & Communication

Primary Language: Ordo/ Paki Translator required: Y

Special Communications Needs: Y Patient is HOH Deaf

Family (specify __N/A_) is HOH Deaf

Hearing aids at BS: N

Sign Language Interpreter Required: N
Isolation: Y Type: Related to: Sepsis

Falls Risk Score: 70 Scale used: Morse Related to: Complete immobile related to UTI infection, confusion due to UTI and fall risk.

Aspiration Risk: N Related to:

Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Bleeding Precautions: N Related to:

Clinical Physical Assessment Findings Analysis of Findings

Week/Dat (Explain significance related to current diagnosis
e in HA
and/or PMH.)
6/15/17 Vital signs: BP: 143/73, Pulse:67, R:18, Temp: 36.8 C, SaO2 97%RA Due to patient being confused and urine-incontinent, there
I:(10Hrs) 375 ml is insufficient measurement of urine output. Onset of
O:(24Hrs) 375 ml incontinence is the only manifestation of an early sign of
UTI.
Blood pressure is elevated, likely associated with dx of
HTN. Need to continue to monitor for any elevation in BP
indicating worsening HTN or increased temperature, HR
or RR indicating possible septicemia. PT’s systolic blood
pressure is normal (<120 and >90), diastolic blood
pressure is lower than normal 60-90) which nonresponses
to the use of the medication prescribed to treat HTP
6/15/17 Neurological/Sensory: Patient not A&O x1 Self, Pupils 3mm bilaterally, Patient not A&O*3. Pt unable to verbally or physically to
unclear speech, inappropriate responses, easily agitated, memory not communicate with medical staff 2º increasing mental
intact, some confusion, facial features symmetrical, no numbness or confusion due to the effects of stroke. Continue monitoring
tingling in arms/legs. patient’s condition and mental status.

6/15/17 Cardiovascular: Pt is currently under medication for HTN and is currently

S1S2 capillary refill< 2 second bilaterally. 1+ peripheral edema lower in stable condition, except for mild edema in lower
extremities, +2 pedal and radial pulse. extremities. Continue monitoring patient's condition.

6/15/17 Respiratory: Both lungs are clear, both anterior and posterior. Pt respiratory is normal and stable; however, continued
monitoring must be done to ensure that patient does not
acquire atelectasis from prolonged bed rest and
immobility.
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

6/15/17 Gastrointestinal & Nutrition: Bowel sounds present in all 4 quadrants, Patient experiences loss of appetite and a sense of feeling
abdomen soft, non-tender. full after he eats 15 % of the meal. The loss of appetite
Patient is on low sodium, cardiac diet, patient is on IV, Patient denies may be due to UTI problem. Monitoring must be done to
nausea and vomiting. Patient has no appetite. ensure that patient is consistently eating and being fed
manually. The patient is unable to feed himself; hospital
nursing staff must manually feed patient.
6/15/17 Musculoskeletal:
+4 muscle strength with slow movements and coordinated. Patient 3/5 upper extremities move against resistance and 1/5
unable to ambulate. lower extremities with no motion. Patient unable to
ambulate and at risk for falls. It is important for him to
keep on non-slip yellow socks at all times. Will continue
to help patient with passive ROM exercises to improve
ambulation. Continue monitoring patient.

6/15/17 Genitourinary/Reproductive: Based on urinalysis and urine culture; this indicates that
Incontinent of urine and urine concentrated with odor. there is infection in the bladder. Monitor patient’s urine
bag to ensure cleanliness and clean skin around the area to
reduce infection.
6/15/17 Integumentary (including incisions and drains): Patient is urine-incontinent due to UTI and being immobile
Skin intake with normal temperature, dry, erythematous patch on sacral with Braden scale of 13 put the patient at the higher risk of
area +blanching. Mucous membranes pale pink, and skin is 13 on pressure ulcers. Continue monitoring patient and
Braden scale decrease skin turgor. consistently turning patient to avoid pressure sores.

6/15/17 IV Assessment: Normal finding, but patient must be constantly monitored,

#20 PIV in left forearm, dressing is clean, dry and intake, IV patent NS and injection site must be cleaned to avoid infection/
currently running. bacteria in Iv injection site.

6/15/17 Pain: Patient pain can be due to his lack of mobility and muscle
Patient complains of 4/10 pain when repositioning. and core weakness/ soreness. Patient to be continually
monitored to make sure pain level does not increase and
that pain is reduced by safe repositioning and by
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

medication.
6/15/17 Psychosocial: Normal Finding: Patient with history of stroke resulting in
Psychosocial: non-verbal, impaired cognitive perception pattern brain injury manifesting itself in the form of aphasia.
Continue monitoring patient
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Ignatavicius, D.D., & Workman, M.L. (2016). Medical-Surgical nursing: Patient-centered collaborative care. St. Louis, MO: Elsevier

Laboratory Tests (relevant admission and current labs)

39

Ignatavicus, D., & Workman, L. (2016). Medical surgical nursing: Patient-centered collaborative care. Elsevier 8th Ed. St. Louis, MI.
Wayne, G. (2016). Ineffective tissue perfusion: Nursing diagnosis & care plan. Retrieved July 6, 2017, from https://nurseslabs.com/ineffective-tissue-perfusion/

Diagnostic Tests (x-rays, CT scans, endoscopies, etc.)

Date Test Reason for test Results/Findings Diagnostic Trend Significance of Result

6/13/17 Esophagogastrodu To further In process N/A pending

odenoscopy (EGD) evaluate the
occurrence of
emesis of blood.
6/13/17 CT angiography To investigate In process N/A pending
abdomen and pelvis masses and tumors
in the abdomen or
pelvis due to
Suspected renal
mass
6/13/17 Urine analysis To further Presence of bacteria N/A UTI/Bladder infection due to E. coli
investigate
Diagnosis of UTI
causing sepsis.
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Medications

List and complete first six columns (drug, does, freq, route, med class, and indications) all ordered mediations.
Complete last five columns (rationale for patient, desired actions, adverse reactions, patient education, and nursing considerations) for five
medications.
 Drug Dos Fre Route Med IndicationRational Desired Adverse Patient Education Nursing
e q Class s e for Action Reactions Consider
Patient Date: ___7/9/2017______ NCP #___Care Plan #2______
Student Name: _______Kampanart Maket (Dew)_______________ ations
Atorvas 40m 1 PO HMC- Primary Atheroscl To Kidney failure, Instruct patient to call the doctor Monitor
tatin g table CoA preventati erosis inhibit fatigue or promptly if muscle weakness and obtain
t reduca ve the weakness, loss of occurs without reason. If patient baseline
Nigh te measure enzyme appetite, upper has allergic reaction including measurem
tly inhibit for found in belly pain, dark swelling of face, lips tongue and ents of
ors patients the liver urine, or throat or symptoms that cause patient’s
(statin with CVD called Yellowing of skin difficulty breathing lipid and
s) or based on HGM- or the white of liver
cholest risk factors CoA the eyes, nausea, measurem
erol associated reductas vomiting, ents. Also
loweri with CVD e, which memory loss, monitor
ng is what confusion. the patient
agents is for signs
responsi of
ble for rhabdomy
the olysis as
synthesi this can
s of affect the
cholester kidneys
ol. This
results in
an
overall
lower
serum
cholester
ol level
associate
d with
risk
CVD.
Insulin Low 3x Subcuta Rapid- Used for Diabetes For the Hypoglycemia, Instruct patient to seek medical Access
lispro wea neous acting individuals Mellitus cells to edema, redness, help right away if they for hypo
kly human with either (Type 2) absorb swelling or experience a rash over the entire glycaemia
insulin type 1 or glucose itching in body, trouble breathing, rapid from 1-3
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Ignatavicius, D.D., & Workman, M.L. (2016). Medical-Surgical nursing: Patient-centered collaborative care. St. Louis, MO: Elsevier

Wilson, B. A., Shannon, M. T., & Shields, K. M. (2017). Pearson nurse's drug guide 2017. Boston : Pearson, (2017).

Nursing Diagnoses
List 5-8 pertinent nursing diagnoses for your patient and prioritize them. You will then choose 2 nursing diagnoses from this list and
expand on them.
Nursing Diagnosis Prioritization

Skin for impaired integrity related to pressure physical immobility. 1

Impaired urinary elimination related to urinary tract infection as evidenced by urinary incontinence and 2
frequent voiding.

Risk of electrolyte imbalance related to excessive fluid volume and sodium imbalance. 3

Imbalance nutrition less than body requirement related to insufficient dietary intake as evidence seen by 4
food intake less than recommended daily allowance or insufficient interest in food.

Risk for fall related to alteration in cognitive function and impaired mobility. 5

Impaired physical mobility related to pain as evidence seen by slowed movement and difficulty turning. 6
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Risk for aspiration r/t SOB, dyspnea, productive cough and patient’s fear and anxiety to choke. 7

Risk for loneliness r/t physical and social isolation, change of environment and affection deprivation. 8

Nursing Diagnosis #1: Functional urinary incontinence

R/T: Alternation in cognitive functioning, AEB: Urinary incontinence, easily aroused from sleep, confused when aroused.
alteration in environmental factor.

SMART Short-Term Goal: By the end of the shift, the patient will learn to utilize the call bell when getting out of bed for the bathroom in
the next 8 hour shift.

Nursing Intervention (including teaching): Rationale for Intervention: Evaluation: Was the short-term goal MET or UNMET?
Substantiate evaluation based on assessment of patient post
intervention.
Place the bell call near the patient’s hand and Have the bell call handy to give the Patient presses the call bell every time he has a need to
remind her to use it if he needs to use the patient peace of mind that she can void or has a request.
bathroom. reach out to his nurse whenever he
needs to.
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Assess the patient’s recognition of the need Patients with functional Patient presses call bell every time when he has the need
to urinate. incontinence are incontinent because to void. The number of calls has increased.
they can’t get to an appropriate
place to void. Institutionalized
patients are often labeled
“incontinent” because their requests
for toileting are unmet. Older
patients with cognitive impairment
may recognize the need to void but
may be unable to express the need.

Establish a toileting schedule A toileting schedule assures the Patient has a set schedule to void regularly
patient of a specific time for voiding
and reduces episodes of functional
incontinence.

Nursing
SMART Intervention
Long-Term (including
Goal:teaching):
By discharge, Rationale
the patient for establish
will Intervention: Evaluation: Was the long-term goal MET or UNMET?
a toileting schedule.
Substantiate evaluation based on assessment of patient post
intervention.
Nurse will educate the patient and caregivers UTI relapses can be prevented with Met, Patient and caregivers will acknowledge the
about prevention of UTI. proper health care. preventive measurements.
Tech family members and other caregivers to Functional continence is promoted Met, Family members and caregivers recognize/response
respond immediately to the patient’s request when caregivers responding to patient’s needs and are able to assist the patient
for assistance with voiding. promptly to the patient’s request for immediately.
help with voiding

Establish a toileting schedule. A toileting schedule assures the Met, Patient has a set schedule to void regularly.
patient of a specific time for voiding
and reduces episodes of functional
incontinence.
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Nursing Diagnosis #2: Impaired Skin integrity.

R/T: pressure physical immobility and AEB: Erythematous patch on sacral area and blanching.
extreme age.

SMART Short-Term Goal: By the end of the shift, the patient’s skin will be dry and intact, no redness.

Nursing Intervention (including teaching): Rationale for Intervention: Evaluation: Was the short-term goal MET or UNMET?
Substantiate evaluation based on assessment of patient post
intervention.
Assess the patient’s ability to move (e.g. shift Scented lotion may contain alcohol Met, Patient is aware; he is able to move, sitting, in bed.
weight while sitting, turn over in bed, move which dries skin. Prescribed solution
from bed to chair). reduces dryness of the scalp and
maintain skin integrity.

Assess for fecal/urinary incontinence. Balanced diet promote healthy skin Met, Patient’s bed and clothes are dry, free of urine and
and healing in the presence of stool.
wounds.
Reassess the skin often and whenever the The incidence and onset of skin Met, Document every time after reassessing the patient’s
patient’s condition or treatment plan results breakdown is directly related to the skin condition and patient’s skin is remaining dry and
in an increased number of risk factors number of risk factors present. moisturized.
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Nursing
SMART Intervention
Long-Term (including
Goal:teaching):
By discharge, Rationale
the patient for no
will Intervention: Evaluation:
longer have the erythematous patchWas
on the long-term
sacral goal MET or UNMET?
is gone.
Substantiate evaluation based on assessment of patient post
intervention.
Nurse will assess the skin condition of Maintenance of skin integrity and Met, Patient’s skin is intact, free of erythematic patches
patient. prevention of pressure ulcers is and other abnormal conditions.
identified as the main key of nursing
intervention. Make sure patient’s
skin is dry and free of erythematic
patches
Nurse will be turning the patient to a Check the patient’s skin for any sign Met, Patient’s skin has no sign of the erythema patch.
different position every 2 hours. of redness and non-bleachable area.
Family member of the patient will be trained Nurse will watch the family member Met, Pt has no ulcers on the pressure points. The Family
by the nurse on how to turn the patient every practice helping the patient being members follow nurse’s commendations.
2 hours. turned. The wife and his daughter will notice any signs of skin
impairment daily.

Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A. (2015). Essentials for nursing practice. St. Louis, MO: Elsevier
Gulanick, M., Myers, J.L. (2013). Nursing care plans: Diagnoses, interventions, and outcomes. (8th ed.). St. Louis MO: Mosby Elsevier.
Nanda International. (2014). Nursing Diagnoses: Definitions and Classification 2015-17 (10th ed.). Hoboken, NJ: Wiley Blackwell
Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______

Reference

Gulanick, M., Myers, J.L. (2013). Nursing care plans: Diagnoses, interventions, and outcomes.

(8th ed.). St. Louis MO: Mosby Elsevier.

Ignatavicius, D., & Workman, M.L. (2016). Medical-Surgical Nursing: Patient-Centered

Collaborative Care (8th ed.). St. Louis, MO: Mosby Elsevier.

McCance, K.L., & Huether, S.E. (2014). Pathophysiology: The biologic basis for disease in adults and children. St. Louis, MO: Elsevier

Nanda International. (2014). Nursing Diagnoses: Definitions and Classification 2015-17

(10th ed.). Hoboken, NJ: Wiley Blackwell.

Wayne, G. (2016). Ineffective tissue perfusion: Nursing diagnosis & care plan. Retrieved July 6, 2017, from

https://nurseslabs.com/ineffective-tissue-perfusion/

Wilson, B. A., Shannon, M. T., & Shields, K. M. (2017). Pearson nurse's drug guide 2017.

Boston: Pearson, (2017).

Student Name: _______Kampanart Maket (Dew)_______________ Date: ___7/9/2017______ NCP #___Care Plan #2______