Running head: COMPREHENSIVE NURSING CARE PLAN 1

Comprehensive Nursing Care Plan

Colleen E. Duckworth

Azusa Pacific University

COMPREHENSIVE NURSING CARE PLAN 2

Nursing Clinical Worksheet

Student Name: Colleen Duckworth Date: 9/7/18
Patient Initials: Age: Sex: Isolation and Type: Code Status: Admit Date:
AAN 70 M C-diff/Enhanced Full 8/29/18
Contact Precautions,
Neutropenic
Precautions
Allergies: Diet: Fall Risk: Braden Activity: LOC: Primary Service (Surgery/Medical):
None NPO Yes Score: Progressive Lethargic 3G-ICU
11 mobility - turn in
bed
Admitting Diagnosis/Chief Complaint (if present in ED):
Multifactorial hypoxia secondary to non-small cell lung cancer/CC: “My breathing is not right”, hypoxia, tachypnea, &
tachycardia

ASSESSMENT DATA:
1. History of Present Problem:

The patient currently has respiratory failure, or acute lung failure (ALF), and left-sided

pneumonia with pleural effusion. He has a history of non-small cell lung cancer (Non-SCLC). On 7/24,

he was seen by his primary care provider with pain and stiffness in his right hip status post fall. At that

time, he had a hip x-ray done which revealed cancerous lesions on the right pelvis. This prompted a

bone scan, done on 8/2, showing numerous lesions in pelvis, ribs, and spine. These results are evidence

for the patient’s new diagnosis of poorly differentiated metastatic Non-SCLC. The patient presented to

the emergency department on 8/29 with hypoxia, oxygen saturation of 88%, tachypnea, and tachycardia

and was then admitted to the ICU. His condition has worsened since then. His white blood cell count has

significantly dropped, and he is on neutropenic precautions. He is on a ventilator with sedation, pain

medication, and vasopressors. His left arm is restrained to keep him from pulling out his endotracheal

tube (ETT). He has been restless and responsive to pain. He has had occasional PVCs with post

ventricular contractions. The patient has a Foley catheter and a fecal containment device. He had watery

diarrhea overnight, and a stool culture to rule out C. difficile was sent. The patient has an OG tube, but

he was placed on an NPO order due to a scheduled stent procedure for today. The night nurse reports

that the procedure may be cancelled. He is scheduled for a diagnostic bronchoscopy and thoracentesis

today. He is supposed to transfer to a Scripps hospital to start chemotherapy in the next week.

2. Past Medical History:

COMPREHENSIVE NURSING CARE PLAN 3

Hypertension

Hyperlipidemia

Diabetes mellitus

CVA with right sided deficit

Unspecified clotting disorder

Recent diagnosis of metastatic Non-SCLC

What is the relationship of your patient’s past medical history (PMH) and current medications? Which medications treat
which conditions?
PMH Home Medications Pharm. Classification
1. hypertension 1. amlodipine 1. calcium channel blocker,
2. hyperlipidemia 2. losartan potassium antihypertensive
3. diabetes mellitus 3. atorvastatin 2. angiotensin II receptor
4. CVA with right calcium antagonist,
sided deficit 4. gemfibrozil antihypertensive
5. insulin (regular) 3. antilipemic, HMG-CoA
6. insulin glargine reductase inhibitor, statin
7. insulin lispro 4. antilipemic, fibrate
8. gabapentin 5. short-acting insulin,
antidiabetic
6. long-acting insulin,
antidiabetic
7. rapid-acting insulin,
antidiabetic
8. GABA neurotransmitter
analog
(Shields, Fox, & Liebrecht,
2018)
Expected Outcome
1. A reduction in systolic, diastolic,
and mean arterial blood
pressure. It does this by blocking
calcium influx across cardiac and
vascular tissue membranes,
which reduces coronary and
peripheral vascular resistance,
increases coronary blood flow
and oxygen delivery, and
increases cardiac output.
2. A reduction in hypertension
through vasodilation and
inhibition of sodium and water
retention. It does this by blocking
angiotensin II receptors.
3. A reduction in LDL and total
triglyceride and an increase in
plasma HDL. It does this by
inhibiting hepatic production of
cholesterol and increasing LDL
receptors.
4. A reduction in total triglyceride
and LDL cholesterol, and an
increase in HDL. It is useful in
patients who have not had
success with diet. It does this by
decreasing VLDL and
triglyceride synthesis.
5. Lowered blood glucose levels. It
does this by stimulating
peripheral glucose uptake of
skeletal muscle and fat,
enhancing protein synthesis and
conversion of glucose to adipose
tissue, and by inhibiting,
lipolysis, proteolysis, and
gluconeogenesis.
COMPREHENSIVE NURSING CARE PLAN 4

6. Extended lowered blood glucose

levels. It does this by stimulating
peripheral glucose uptake of
muscle and fat and by inhibiting
hepatic glucose production.
7. Rapidly lowered blood glucose
levels. It does this by increasing
peripheral glucose uptake of
skeletal muscle and fat tissue and
by inhibiting glycogenolysis.
8. Treatment for painful peripheral
neuropathy, associated with
diabetes mellitus and right sided
deficits from stroke in this
patient.

(Shields et al., 2018)

BEGINNING OF PATIENT CARE:

Doc Flowsheet Data

Vital Signs 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700
Noninvasive Blood Pressure (NIBP) (Left Arm) 70/38 149/50 174/59 142/59 140/60 130/74 128/60 147/69 166/70 154/6
6
Mean Arterial Blood Pressure (MAP) 49 83 97 87 87 93 83 95 102 95
Pulse Rate 101 88 87 90 89 80 88 80 89 85
Respiration Rate (RR) 16 18 20 18 20 16 18 20 15 20
% O2 Saturation (SpO2) (ETT) 94 97 96 97 100 94 97 99 98 100
Temperature (R axillary) 99.4 99.4 99.4 99.4 99.4 99.2 99.3 99.2 99.2 99.0
Other 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700
Pain Level (CPOT) 0 0 0 0 0 0 0 0 0 0
Sedation Level (RASS) -2 0 +1 0 +1 -1 0 0 +1 0
Blood Glucose (POC) 121 111 107 107 108 98 94 95 80 78
Intracranial Pressure (ICP) N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
Hemodynamic 0800 0900 1000 1100 1200 Ventilator Settings IV Fluids
Monitoring
Arterial Blood 63/34 150/53 184/75 145/55 150/53 Type Rate/ Site
Pressure (ABP) Lactated 999 ml/hr/ Right
Central Venus N/A N/A N/A N/A N/A Mode: VTPC/CMV ringers 1,000 AC Peripheral
Pressure (CVP) mL IV bolus IV 20 g
Pulmonary Artery N/A N/A N/A N/A N/A once
Pressure (PAP) Rate: 16
Pulmonary Artery N/A N/A N/A N/A N/A
Occlusion Pressure
(PAOP)
Cardiac Index N/A N/A N/A N/A N/A
Cardiac Output (CO) N/A N/A N/A N/A N/A TV: 500 Sodium 10 mL/hr/Left IJ
Hemodynamic 1300 1400 1500 1600 1700 chloride CVC Triple
0.9% (TKO) Lumen
Monitoring Continued FiO2: 60%
Arterial Blood 147/68 139/62 171/71 173/74 165/59
Pressure (ABP)
Central Venus N/A N/A N/A N/A N/A
Pressure (CVP) PEEP: 8
Pulmonary Artery N/A N/A N/A N/A N/A
Pressure (PAP)
COMPREHENSIVE NURSING CARE PLAN 5

Pulmonary Artery N/A N/A N/A N/A N/A PS: N/A Sodium Intermittent
Occlusion Pressure chloride flushes, Right
(PAOP) 0.9% Radial ART
Cardiac Index N/A N/A N/A N/A N/A
Cardiac Output (CO) N/A N/A N/A N/A N/A
Intake (mL per shift) Output (mL per shift)
Intake/Output
Oral Enteral IV TOTAL Urine BM Emesis Drains TOTAL
Shift Total N/A N/A 2348 2348 610 1000 (3 N/A N/A 1610
episodes of
liquid
diarrhea
this shift)
Please state why there is a significant difference in the I/O (if any): The patient’s intake is significantly higher than output this
shift, with a difference of 738 mL. The patient is taking vasopressin, an antidiuretic hormone, which explains why there is less
urine output (Shields et al., 2018).

HR Rhythm P wave PR QRS P:Q ratio ST segment T-wave Q-T Ectopy

82 NSR 0.12 sec 0.20 sec 0.04 sec 1:1 Depressed Normal 0.32 sec, Normal None
Interpretation:
Normal sinus rhythm at 82 beats/min

Complete Head-To-Toe Assessment

Physical Weight = 64 kg, well nourished, sedated, ventilated
Appearance
General Mood Occasionally agitated and anxious, sedated, responds to voice with eye contact intermittently
Survey
Signs of Acute Occasional agitation and anxiety, resistance against restraints
Distress
Orientation Intubated/sedated, Poor safety awareness, Unable to future assess
Speech Unable to assess - intubated/sedated
Pupil (L) 2 mm PERRLA
Neurologic Pupil (R) 2 mm PERRLA
GCS score 10 = 4, 1, 5
Abnormal Location: R upper and lower extremities
Muscles Strength: 1/1, flicker of intention
Provocation/ Lack of pain medication
palliation
Pain Quality Cancer pain
Assessment Region/ Diffuse
Radiation
Severity Varies
Time Intermittent
Oxygenation ☐ Room Air ☐x Device: ETT Flow rate: 16 L/min
Pulmonary Respiration Quality: Ventilated, Suctioning produces yellow, white, thick mucous
Rate: Regular
COMPREHENSIVE NURSING CARE PLAN 6

Rhythm: Regular
R. Lung Clear upper and middle breath sounds, Diminished lower breath sounds, Chest rise higher on
the right than left
L. Lung Absent upper and lower breath sounds
Capillary Refill <2 seconds
Skin Color/ Normal for ethnicity, warm, no tenting, trace edema in right upper and lower extremities
Temp
Cardio- Apical Pulse Normal, 80 bpm
vascular
Heart Sounds Normal S1 and S2
Peripheral Normal
Pulses
Oral Mucosa Dry, Several ulcers on gums, lips, and tongue, ETT in place, Frequent oral care provided by
RT
Tongue Dry, Ulcerations
Abdomen Soft, non-distended, normoactive bowel sounds
Nutrition NPO since this midnight
Gastro-
Tube Feeding Current Rate: _N/A__________ Goal Rate: _N/A____________
intestinal
Residuals: N/A_ Type: ☐ N/A ☐ NGT ☐ PEG ☐ J-tube ☐x OG-tube, not in
use, placed on 9/1, 16 French, secured at the teeth at 26
Bowel Sounds Hyperactive in all four quadrants
Bowel Last BM date: Today_____
Movement
Urination Through indwelling Foley catheter
Urine Color Amber
Urine Clear
Genito- Character
urinary Urine (ml) 610, Average 50 mL/hr
Urinary Insertion date: 9/1, no signs of infection
Catheter
Skin Color Redness without blanching
Skin Integrity At risk
Skin Wound/ 5x5 cm area on sacral region, covered by Mepilex sacral dressing
(wounds) Ostomy
Insertion Site(s) Right AC Peripheral IV, Left IJ central line, Right radial ART line
IV Assessment No signs of phlebitis, no redness, inflammation, or purulence
IV Fluids Normal saline & lactated ringers
Musculo- Describe Soft-restraint applied to left wrist, 1/1 strength with flicker of intention in right upper and
skeletal abnormalities: lower extremities r/t previous CVA

Psychosocial Assessment
Marital status Married
Education level Medical doctor
Social resources Lives with son, son visited the patient during the shift
Psychosocial Spiritual resources Unknown, unable to assess
History Occupation Hematologist
Employment Retired
Smoking 50 pack year smoking history, quit for 3 years, ¼ ppd in last year
Alcohol None
Recreational Drugs None

Spiritual Assessment
COMPREHENSIVE NURSING CARE PLAN 7

Spiritual
Spiritual Integrity 1) Look: (Signs of Meaning, Relationships, Hope and Joy)
Distress
Presence of….. Provide checkmark in either box for each criteria Absence of….
X Family, friends, visitors, wedding ring, photographs
Cards, letters, phone calls, flowers, pets X
Attention to personal care and appearance X
Work, projects, hobbies, music, books, tapes X
Newspapers, magazines, television, radio X
Special dress, prayer cap, head scarf, cross X
Articles of faith, pictures, statues, rosary, star X
Books of faith, Bible, Koran, Torah prayers X
Smiles, motivation, coping skills, healthy lifestyle X
Uses the observations listed above to begin your Spiritual Assessment
Acknowledge and inquire about photographs, cards, flowers, visitors
Acknowledge and inquire about hobbies, books, television/newspaper content
Acknowledge strength and inquire about profession
Acknowledge and inquire about articles of faith & religious preference
Acknowledge and inquire about mood (physical and psychological)
With your client as your guide, and after a sense of trust and connectedness have been established, continue with the assessment.
Phrase your questions and indirect statement in ways that convey your genuineness, style, and comfort.
I wasn’t able to ask any of these questions to the patient directly, because he was sedated and on a ventilator.

The best response I was able to get was eye contact. The patient’s son came to visit the patient, and the patient had a

more positive response to him; with shaking and nodding his head. Unfortunately, the son was not able to stay for

very long, and I wanted to give them private time. I would have liked to have asked the patient or his son if he knew

more about the patient’s goals, things that make him happy, where his sources of strength and refuge are, and if he

has things to look forward to.

Spiritual Integrity Listen: (Actively listen for signs of meaning, relationships, hope, and joy) Spiritual Distress
**Provide checkmark in each box that is applicable:
Pt verbalizes... Pt verbalizes…
Patient is unable to verbalize any of these concepts.
Sense of purpose and meaning My life has no meaning
Source of pride & accomplishment Guilt, if only….I should have
Source of joy & happiness Sense of sadness and despair
Future Goals and desires Lack of motivation
Hope and Courage Hopelessness “What is the use?”
Interest in world & concern for others Lack of concern for others
Personal Strengths Powerlessness I am useless.
Connection to others Loneliness and isolation
Connection to a higher source Helplessness, anxiety, fear
Religious affiliation “This is not fair. Why me?”
Request for special diets, clergy “Why am I being punished?”
Appreciation for nature Apathy
Ability to adapt to changes Inflexibility
2. Nursing Diagnosis: Analyze the data, and if appropriate, select one of the following nursing diagnoses.
Potential for Enhanced Spiritual Well-Being
Spiritual Distress
COMPREHENSIVE NURSING CARE PLAN 8

Hopelessness related to loss of control and terminal illness as evidenced by anxiety, agitation, and isolation (Ackley, Ladwig,
x
& Flynn Makic, 2017)
Other
3. Plan: Develop a short-term goal and a long-term goal for your client.
ST Goal: The client will show reduced anxiety and agitation by exhibiting no higher than a +2 RASS score throughout the shift.
LT Goal: The client will answer through yes or no questions whether he has any goals in life that he still wants to accomplish before he
passes, and he will have time to reflect on these goals and think of a how to implement them by time of discharge.
4. Interventions: Identify the specific nursing interventions you will use with your client.
X Be present.
X Establish a therapeutic relationship conveying respect, warmth, empathy and genuineness
Active listening.
Assist client to identify strengths, supports, and interconnections.
X Instill hope.
X Use of touch, if client is comfortable with closeness.
X Provide an environment conductive to reflection, prayer, and spiritual growth.
Provide an environment conductive to client’s beliefs (food, ceremonies.)
Provide religious articles as requested.
Support client in search for meaning and purpose in life, illness, and death
Support client in search for a relationship with a higher power.
Pray with the client.
X Pray for the client.
X Promote private time with people who are significant in client’s life.
X Be available and approachable to assist client with meeting spiritual needs, and making spiritual choices.
Collaborate with chaplain or spiritual leader.
X Other: Assess for pain and provide pain medication (Ackley et al., 2017)
X Other: Encourage the patient’s son to come back to visit frequently, since it improved the patient’s response and mood
(Ackley et al., 2017).
5. Evaluation: Evaluate the client’s progress towards the goals.
(Note: Each person’s spirituality is highly variable, individual, and ever changing!)
ST Goal: The goal was met; the patient’s highest RASS score was +1 throughout the shift.
LT Goal: I expect the patient to meet this goal if his sedation is not too heavy throughout his entire discharge, because it is an appropriate
time to think of what he would like to do in life before he passes. I expect that he will an environment conducive to this, visitors, and
encouragement throughout his hospital stay.
**This Client Spiritual Assessment Tool (CSAT) was adapted from: Hoffert, D., Henshaw, C., & Mvududu, N. (2007). Enhancing the ability of nursing
students to perform a spiritual assessment. Nurse Educator, 32(2), 66-72.

What vital sign data are relevant that must be recognized as clinically significant?

Relevant Vital Sign/Assessment Data: Clinical Significance:

1. Oxygen saturation 1. Preventing desaturation of oxygen is critical in this patient due
2. Respiratory rate to his ALF, pneumonia, and non-SCLC. A pulse oximeter should
3. Temperature always be worn. The patient’s ventilator settings should be
adequately adjusted by the RT to ensure that the patient does not
develop hypoxia again (Urden, Stacey, & Lough, 2018).

2. It is important to monitor respirations of the patient while he is

on mechanical ventilation. He should be breathing deeply and
adequately enough so that he is able to get enough oxygen and
expel enough carbon dioxide. Difficulty breathing can be expected
due to ALF, pneumonia, and non-SCLC (Urden et al., 2018).
COMPREHENSIVE NURSING CARE PLAN 9

Changes in respiratory rate are also side effect of some of the

patient’s medications (Shields et al., 2018).

3. Temperature is elevated in patients with sepsis, and this is a

likely complication due to the current infections and low WBC
count (Urden et al., 2018)

RADIOLOGY REPORTS AND LAB VALUES:

What diagnostic and lab results are relevant that must be recognized as clinically significant for the nurse?
Relevant Results: Clinical Significance:
(Date)
X-ray, Right hip 7/24 Numerous lesions in right pelvis. It is significant because it was the first time that metastasis was
(outpatient) noted, so it provides a baseline and more importantly, an indication for further tests. It is a low-
cost procedure, which makes it ideal for an initial test (Malarkey & McMorrow, 2012).
Bone Scan, 8/2 Numerous lesions in pelvis, ribs, and spine. This test is helpful for finding the amount and extent
(outpatient) of metastatic cancer in the bone (Malarkey & McMorrow, 2012).
CT Scan, PE 8/29 Neoplastic process in left upper lobe with associated airspace engulfment of left pulmonary
artery trunk and left bronchus. 6.9 x 7.2 cm ground glass opacities and consolidation in apex of
left upper lobe, nodal conglomeration centered in AP window/left hilar region. This test is useful
because it helps identify the size, shape, and structure of abnormalities in the patient’s lungs
(Malarkey & McMorrow, 2012).
CT Scan, Head w/out Left post-central gyrus hypodensity, hypodensity in left posterior parietal lobe compatible with
contrast 9/1 vasogenic edema surrounding brain metastasis, known acute/early subacute infarct, no acute
intracranial hemorrhage. The absence of ICH is important because it rules out contraindication
for heparin, and the presence of ICH is possible with the patient’s norepinephrine use (Sheilds et
al., 2018). This test is useful for showing abnormalities within the brain and skull. This test is not
as specific as an MRI (Malarkey & McMorrow, 2012).
X-ray, Chest 9/7 Near complete white out of left hemithorax – large effusion. Stable chest and support devices.
This test revealed a serious pulmonary condition associated with the patient’s complicated
medical history (Malarkey & McMorrow, 2012).
MRI, Brain & Spine w/o Brain: Enhancing lesions consistent with multifocal intracranial metastasis.
& w/ contrast 9/2 Spine: Abnormal edema and enhancement is present at T5, T7, T8, suggesting marrow
involvement. C2-C5 unassessed. This is a noninvasive test that is useful for showing biochemical
differences among tissues such as those evident in this patient (Malarkey & McMorrow, 2012).
Bronchoscopy 9/7 Results are pending. This test allows for inspection of the lower respiratory tract. It is useful for
visualization of the tracheobronchial tree that is more direct than imaging studies (Malarkey &
McMorrow, 2012).
Thoracentesis 9/7 Results are pending. This was done diagnostically, rather than therapeutically. It was done
because there is an abnormal accumulation of pleural fluid. Collection of the fluid allows for
better identification of cancer and infection in this patient (Malarkey & McMorrow, 2012).

What lab results are relevant that must be recognized as clinically significant to the nurse?

Lab Order(s): Current Values: Previous Values: Clinical Significance of Lab Values: Why was this test
(Normal Range) (N/H/L) N/H/L) ordered, and what is the significance of the value? Are
N = Normal N = Normal there any trends (improved, worsened, stable)?
H = High H = High
L = Low L = Low
COMPREHENSIVE NURSING CARE PLAN 10

Complete Blood 9/7/18 @ 0211 9/6/18 @ 0405

Count
WBC 0.6 L 3.0 L Worsened. This is life threatening because of the inability
to fight off active and potential additional infections. This
patient has bone marrow depression due to metastatic
cancer with bone involvement (Malarkey & McMorrow,
2012). A low value is also a side effect of the patient’s
dexamethasone use (Shields et al., 2018).
Hgb 7.4 L 7.6 L Worsened. This may be due to fluid retention and a lack of
red blood cells. The production of red blood cells is
decreased because of bone metastasis (Malarkey &
McMorrow, 2012).
Hct 25.4 L 25.5 L Worsened. This may be due to fluid retention and a loss of
red blood cells. The production of red blood cells is
decreased because of bone metastasis (Malarkey &
McMorrow, 2012).
Platelets “CLUMPED” 126 L Low. The patient’s bone marrow is not producing enough
platelets. This provides a baseline before starting
chemotherapy or radiation treatment. Since it is low, the
patient is likely no longer a candidate for chemotherapy at
this time (Malarkey & McMorrow, 2012).
Neutrophils Not done Not done I was unable to find this value in the patient’s chart. This is
likely because the patient is taking filgrastim, which
artificially stimulates neutrophils. I would monitor that this
value not exceed 10,000/mm3 with this medication (Shields et
al., 2018).
Basic Metabolic Panel 9/7/18 @ 1545 9/7/18 @ 0211
Sodium 142 142 Stable
Potassium 4.5 4.3 Stable
Glucose 78 105 Stable
BUN 54 H 56 H Improving. This is normally excreted by the kidneys. Since
the value is high, the patient may be dehydrated and have
poor renal blood flow (Malarkey & McMorrow, 2012).
High BUN is also a side effect of ceftazidime,
corticosteroid therapy (dexamethasone), and vancomycin
(Shields et al., 2018).
Creatinine 0.89 0.84 Stable
Calcium 8.2 L 8.2 L Stable, but low. Altered renal filtration and resorption can
cause hypocalcemia. A low finding is often seen in
patients with low albumin, which this patient also has
(Malarkey & McMorrow, 2012).
Chloride 106 106 Stable
Bicarb 23 24 Stable
Other Labs:
8/30 8/29
Bilirubin total mg/dL 0.26 0.37 Stable
Albumin g/dL 2.2 L 2.6 L Low, worsening. This is a common finding in patients with
metastatic cancer (Malarkey & McMorrow, 2012).
Protein total g/dL 6.2 6.3 Stable
ALP u/L 204 197 High, worsening. This is a possible sign of the patient’s
healing hip injury and possible involvement of cancer to
the liver (Malarkey & McMorrow, 2012). This is also an
adverse effect of ceftazidime and filgrastim (Shields et al.,
2018).
COMPREHENSIVE NURSING CARE PLAN 11

ALT IU/L 19 22 Stable

AST U/L 24 26 Stable
9/7 @ 0539 9/6 @ 1950
Lactate mmol/L 0.9 1.4 Stable
Phosphorus mg/dL 3.2 2.8 Stable
Magnesium mh/dL 2.5 H 2.4 Worsened. This suggests that the patient may have renal
failure (Malarkey & McMorrow, 2012).
ABG 9/7 @ 0024 9/6 @ 0405
FiO2 40.0 40.0 Stable
Temp C 36.7 36.7 Stable
pH 7.41 7.47 H Improved. This means that the patient was in an alkalotic
state. It is a good sign that the patient’s pH returned to a
normal state so that his cells are able function properly
(Malarkey & McMorrow, 2012).
pCO2 mmHg 41 39 Stable
pO2 mmHg 81 82 Stable
HCO3 mmol/L 26 28 H Improved. The patient may have lost too much acid
through the urine loss or corticosteroid therapy
(dexamethasone) (Malarkey & McMorrow, 2012).
BE mmol/L 1.7 4.5 H Improved. A base excess greater than 2 coincides with
metabolic alkalosis (Malarkey & McMorrow, 2012).
O2 sat % 95.7 96.3 Stable
Cultures:
MRSA nares 8/30: Negative No comparison No comparison
Respiratory 9/7: Pending 9/2: Moderate Collection of the fluid allows for better identification of
WBCs, Moderate cancer and infection in this patient (Malarkey &
gram-positive McMorrow, 2012).
cocci in clusters,
Normal
respiratory flora
Blood 9/6: No growth No comparison No comparison
Urine 9/6: No growth No comparison No comparison

Scheduled Medications and PRN Medication Given

Generic Name: ceftazidime Trade Name: Fortaz
Classification: Third generation cephalosporin, Dose: 1,000 mg Route: IVPB Frequency/ Rate: q 8 hrs/ 25 mL/hr
antibiotic in NS 50 mL
Pt. Specific Indications: For treatment of pneumonia and the patient’s high risk of further infection
Mechanism of Action: binds to essential penicillin-binding proteins, acts against gram-negative and gram-positive bacteria
Contraindications: sensitivity to cephalosporins
Side Effects: abdominal pain, nausea, vomiting Adverse Effects: increased ALT and ALP
Patient Family Education: Report watery diarrhea
Nursing implications/actions: Monitor for hypersensitivity reactions, report watery diarrhea, this can contribute to confusion,
monitor renal labs
Generic Name: dexamethasone Trade Name: Decadron
Classification: Adrenal corticosteroid, Dose: 4 mg Route: IV Frequency/ Rate: q 12 hrs/ 4 mg/2 min
glucocorticoid, anti-inflammatory
Pt. Specific Indications: For reduction in inflammation in the lungs, neoplasias
Mechanism of Action: prevents accumulation of inflammatory cells
Contraindications: hypersensitivity, acute infections
Side Effects: insomnia, psychic disturbances, increased ICP, Adverse Effects: edema, hyperglycemia, impaired wound
nausea healing
COMPREHENSIVE NURSING CARE PLAN 12

Patient Family Education: This contributes to immunosuppression, report nausea, vomiting, muscular weakness and pain, avoid sources
of infection
Nursing implications/actions: Give over 2 minutes, report signs of Cushing’s syndrome
Generic Name: filgrastim Trade Name: Zarxio
Classification: Hematopoietic growth factor, Dose: 480 mcg Route: SC Frequency/ Rate: q A.M./ continuous
antineutropenic
Pt. Specific Indications: This helps treat chemotherapy induced neutropenia and mobilizes blood stem cells
Mechanism of Action: This regulates production of neutrophils within the bone marrow
Contraindications: ARDS, Do not give while currently receiving chemotherapy
Side Effects: ST segment depression, chest pain, anemia, cough, Adverse Effects: dizziness, fatigue, rash, hyperuricemia,
dyspnea, bone pain anemia, thrombocytopenia, increased ALP
Patient Family Education: report bone pain
Nursing implications/actions: Stored in refrigerator, assess for bone pain, monitor CBC, discontinue if neutrophil count exceeds
10,000/mm3
Generic Name: heparin sodium Trade Name: Hepalean
Classification: Anticoagulant Dose: 5,000 Route: SC Frequency/ Rate: q 12 hrs/ 2 mL/min
units (in 1 mL)
Pt. Specific Indications: The patient has a moderate VTE risk level
Mechanism of Action: Affects the clotting cascade, blocks to conversion of prothrombin to thrombin and of fibrinogen to fibrin
Contraindications: Hypersensitivity, active bleeding, suspected intracranial hemorrhage
Side Effects: fever, chills, rash, numbness and tingling in hands Adverse Effects: spontaneous bleeding, thrombocytopenia,
and feet, nasal congestion, conjunctivitis, hyperkalemia, bronchospasm, anaphylactoid reactions
suppressed renal function, rebound hyperlipidemia
Patient Family Education: Protect from injury, report chest pain, dark urine, bleeding oral mucosa
Nursing implications/actions: Monitor vital signs, report fever, drop in blood pressure, tachycardia, observe injection sites for signs
of infection, alternate injection sites, monitor coagulation tests and CBC
Generic Name: metronidazole Trade Name: Flagyl
Classification: antitrichomonal, amebicide, Dose: 500 mg Route: IVPB Frequency/ Rate: q 8 hrs/ 100 mL/hr
antibacterial
Pt. Specific Indications: For treatment of pneumonia and suspected C. difficile infection
Mechanism of Action: Has trichomonacidal, amebicidal, and antibacterial activity, acts on gram-negative anaerobic bacteria and
Clostridia
Contraindications: hypersensitivity, new abnormal neurologic signs
Side Effects: polyuria, nausea, vomiting, diarrhea, dry mouth, Adverse Effects: candida, flattening of T waves
confusion, insomnia, drowsiness
Patient Family Education: Urine may be dark, but this has no clinical significance, report candidal overgrowth on tongue
Nursing implications/actions: Check y-site compatibility, monitor for signs of seizures, monitor for sodium retention, report
candidiasis, repeat stool culture, monitor WBC counts
Generic Name: vancomycin hydrochloride Trade Name: Vancocin
Classification: antibiotic, glycopeptide Dose: 750 mg Route: IVPB Frequency/ Rate: q 12 hrs/ 250 mL/hr
in NS 250 mL
(3 mg/mL)
Pt. Specific Indications: For treatment of pneumonia and suspected C. difficile infection
Mechanism of Action: inhibition of cell-wall biosynthesis, alteration of cell-membrane permeability and RNA synthesis, for gram-
positive bacteria
Contraindications: hypersensitivity
Side Effects: hypotension, chills, warmth, nausea, rash Adverse Effects: nephrotoxicity, rash, chills, fever,
hypotension shock-like state, anaphylactoid reaction with
vascular collapse, leukopenia
Patient Family Education: Full course must be completed, may cause ringing in ears
Nursing implications/actions: Check y-site compatibility, monitor blood pressure and heart rate, monitor I&O, monitor renal
function tests
Generic Name: fentanyl citrate Trade Name: Sublimaze
Classification: analgesic, narcotic Dose: 2500 Route: IV Frequency/ Rate: continuous/ 0-20
mcg/250 mL mL/hr
infusion (10
COMPREHENSIVE NURSING CARE PLAN 13

mcg/mL, 0-200
mcg/hr)
Pt. Specific Indications: For analagosedation/analgesia and sedation
Mechanism of Action: narcotic agonist
Contraindications: hypersensitivity, substance abuse history, MAO inhibitor use in the last 14 days, significant respiratory
compromise
Side Effects: respiratory depression, reduced alveolar ventilation, Adverse Effects: circulatory depression or arrest,
sedation, euphoria, diaphoresis, nausea, vomiting, constipation, bronchoconstriction, respiratory depression or arrest, muscle
flatus, rash rigidity
Patient Family Education: Avoid hazardous activities
Nursing implications/actions: Check compatibility, monitor vital signs, watch for muscle rigidity and weakness, respiratory
depression could last longer than analgesia, have intubation equipment, Black box warning
Generic Name: insulin regular Trade Name: Humulin R, Novolin R
Classification: short-acting insulin, Dose: 100 units Route: IV Frequency/ Rate: continuous/ 0-60
antidiabetic in NS 100 mL mL/hr
(0-60 units/hr)
Pt. Specific Indications: Promotion of intracellular shift of potassium, regulation of blood glucose, and for counteraction of
hyperglycemia from norepinephrine use
Mechanism of Action: Stimulation of peripheral glucose uptake of skeletal muscle and fat, enhancement of protein synthesis and
conversion of glucose to adipose tissue, and inhibition of lipolysis, proteolysis, and gluconeogenesis
Contraindications: hypersensitivity
Side Effects: nausea, sweating, palpitations, tachycardia, Adverse Effects: anaphylaxis, coma, urticaria,
weakness, fatigue, hypothermia lymphadenopathy
Patient Family Education: blood glucose needs to be checked regularly
Nursing implications/actions: Check compatibility, monitor I&O, blood pressure, blood glucose

Generic Name: norepinephrine bitartrate Trade Name: Levophed

Classification: adrenergic agonist, vasopressor, Dose: 8 mg in Route: IV Frequency/ Rate: continuous/ 0-56.3
cardiac inotropic NS 250 mL (0- mL/hr
30 mcg/min)
Pt. Specific Indications: For a target MAP of 65-85 mmHg. To increase systolic and diastolic blood pressure, myocardial
oxygenation, and coronary artery blood flow. This is needed because the patient is on sedation medications.
Mechanism of Action: Acts on alpha-adrenergic receptors and mildly on beta1 receptors (in the heart), constricts blood vessels and
stimulates the heart
Contraindications: profound hypoxia or hypercarbia, hypertension
Side Effects: tremors, headache, dizziness, sweating, palpitations, Adverse Effects: Hepatic necrosis, renal necrosis, fatal
reflex bradycardia, hypertension, hyperglycemia arrhythmias, severe hypertension, violent headache, cerebral
hemorrhage
Patient Family Education: Circulatory inadequacy can occur after cessation of this medication
Nursing implications/actions: Check compatibility, monitor I&O, be alert to cardiac and vascular changes, If MAP < 50 mmHg,
double infusion rate every 1 minute up to 30 mcg/min, then contact provider, Black box warning
Generic Name: propofol Trade Name: Diprivan
Classification: general anesthesia, sedative- Dose: 10 Route: IV Frequency/ Rate: continuous/ 0-21
hypnotic mg/mL (0-60 mL/hr
mcg/kg/min;
weight = 58.4
kg)
Pt. Specific Indications: For a RASS score of 0 to -2, for conscious sedation and anesthesia while patient is mechanically ventilated
Mechanism of Action: Acts as a sedative-hypnotic, with a rapid onset of 40 seconds
Contraindications: hypersensitivity, increased ICP, impaired cerebral circulation
Side Effects: twitching, bucking, jerking, trashing, Adverse Effects: ventricular asystole
clonic/myoclonic movements, hypotension, headache, dizziness,
cough, apnea, vomiting
Patient Family Education: This is useful for sedation while the patient is mechanically ventilated
Nursing implications/actions: Check compatibility, monitor hemodynamic status, implement seizure precautions, prepare for
excitation with restraints, Turn off if MAP < 50 mmHg, then contact provider, change drug and tubing every 6 hours
COMPREHENSIVE NURSING CARE PLAN 14

Generic Name: vasopressin Trade Name: Vasostrict

Classification: pituitary hormone, antidiuretic Dose: 40 units Route: IV Frequency/ Rate: continuous/ 2.4 mL/hr
hormone (ADH) in NS 40 mL
(0.04
units/min)
Pt. Specific Indications: For a target MAP of 65-85 mmHg. Treats hypotensive and septic shock, which the patient is at risk for.
Mechanism of Action: Increases tubular reabsorption of water, contracts smooth muscles of GI tract and vascular system
Contraindications: hypersensitivity, nephritis, nitrogen retention, ischemic heart disease, PVCs, arteriosclerosis
Side Effects: tremor, sweating, pallor, nausea, vomiting, Adverse Effects: anaphylaxis, cardiac arrest, MI, cardiac
bradycardia, edema arrhythmia, water intoxication, coma
Patient Family Education: pay attention to urinary output
Nursing implications/actions: Turn off if MAP > 100 mmHg, then contact provider, monitor I&O, assess for alertness and
orientation
(Shields et al., 2018)

BEGINNING OF CLINICAL REASONING:

CLINICAL REASONING: Pathophysiology of Admitting Diagnosis

(Describe pathophysiology as you would explain it to the patient.)

You currently have ALF, related to metastatic non-SCLC and left-sided pneumonia and pleural

effusion. Having ALF means that your lungs are not able to obtain oxygen and expel carbon dioxide on

their own requirements (Urden et al., 2018). It was likely caused by the malignancy of non-SCLC,

which classifies it as extrapulmonary ALF (Urden et al., 2018). Your natural drive to breathe, muscle

strength, normal pulmonary function, and elasticity of your chest are decreased. You have more

resistance that you have to work against to breath, and you have greater oxygen needs (Urden et al.,

2018). The demand that your tissues had for oxygen was not met when you were first admitted, which is

why hypoxia and hypoxemia developed (Urden et al., 2018). Currently, your arterial blood gas labs are

normal, which means that we have been able to correct some of your impaired gas exchange with the

use of the mechanical ventilator (Urden et al., 2018). Treating the underlying cause will require

treatment of non-SCLC, which you are scheduled to have beginning next week if we can get you stable

enough to do so (Urden et al., 2018). It has not been ordered, but medications that help expand your

airways would help with WLF (Urden et al., 2018). Positioning you on your right side would help, since

your left lung is the most involved; however, I have been told that you don’t like to be on that side

because of the flaccidity from your previous stroke. We can also elevate the head of the bed to 30 and 45

degrees, sedate you to control anxiety and provide plenty of rest to minimize use of oxygen (Urden et
COMPREHENSIVE NURSING CARE PLAN 15

al., 2018). We can give you IV fluids and provide suctioning to promote clearance of your secretions

(Urden et al., 2018). Unfortunately, the prognosis of your lung condition is poor, with one-third of

patients with ALF on a ventilator pass away in the hospital (Urden et al., 2018).

Your pneumonia is a bacterial infection in your left lung, correlated to your non-SCLC, and

compounded by your history of cigarette smoking, inhalation, passage of organisms down into your

airway through increased saliva secretions, intubation/ventilation, being in a supine position, from

having a depressed immune system, or through a reactivation of previous infection (Urden et al., 2018).

Lungs have different types of normal bacteria, but a stressful event, such as your chronic illness, harmful

bacteria invade and outgrow the normal bacteria (Urden et al., 2018). The infection contributes to

inflammation, which makes the small blood vessels in your lungs, called capillaries, more susceptible to

fluid accumulation and transfer through the vessel walls. A pleural effusion is a common complication

of pneumonia, because fluid from those capillaries finds its way into the pleural space, which is the

space between your lungs and the cavity in which your lungs live (Urden et al., 2018). Pus accumulation

also occurs in the small sacs in your lungs, called alveoli, which is where oxygen transport to the blood

normally occurs. The pus makes breathing more difficult and it makes your lungs have a harder time

expanding and contracting (Urden et al., 2018). Some of the symptoms and signs you have had since

you were admitted to the hospital are related to pneumonia. You have experienced not being able to

breath or breathing too quickly, coughing, and low oxygen delivery to your tissues (Urden et al., 2018).

We have tried to mediate these affects by placing a tube down your lungs and having a machine help

you breathe with mechanical support and supplemental oxygen. Your laboratory results have also

showed reduced white blood cells, which is a sign of pneumonia. We expect that the antibiotics you are

currently taking should help cure the infection. We cultured your blood which showed no growth, and

we are waiting on your lung fluid cultures to give us more information on the cause and status of your

infection. Once we find out these results, we will be able to change your antibiotics to something more
COMPREHENSIVE NURSING CARE PLAN 16

specific, if needed. The prognosis of pneumonia in conditions similar to yours is a mortality rate of 50%

(Urden et al., 2018).

NURSING CARE PRIORITIZATION: List 4 Nursing Diagnoses In Order of Highest Priority

(Based on your patient’s specific needs, identify four nursing diagnosis and rank them in order of importance; be sure to include
at least one physiologic and one psychosocial diagnosis)

(1) Impaired gas exchange related to alveolar hypoventilation, as evidenced by recent abnormal ABG values,
restlessness, confusion, and recent PVCs.

(2) Ineffective airway clearance related to excessive secretions, as evidenced by yellow, white, thick mucus secretions
that need to be suctioned every hour and diminished/absent breath sounds.

(3) Acute confusion related to sensory overload, sensory deprivation, and sleep pattern disturbance, as evidenced by
agitation and a disordered sleep/wake cycle.

(4) Risk for sepsis infection related to inadequate secondary defenses, use of a corticosteroid, invasive procedures, low
white blood cell count, malnutrition, and chronic diseases.

NURSING CARE PLAN:

(Select 2 of your nursing diagnoses listed above and create a nursing care plan for each. Provide 1 short term goal, 3
interventions with rationales, and include if goal was met, not met, or in progress AND 1 long term goal, 3 interventions with
rationales, and include if goal was met, not met, or in progress)

1. NSG DX #1: Ineffective airway clearance related to excessive secretions, as evidenced by yellow, white, thick mucus
secretions that need to be suctioned every hour and diminished/absent breath sounds.
(a) NURSING ASSESSMENT
a. Related Assessments: sputum, clinical manifestations of pneumonia including breath sounds and fever
b. Related Labs and Tests: cultures, bronchoscopy, thoracentesis, chest x-ray, CT PE, MRI spine
c. Relevant Meds: dexamethasone, filgrastim, ceftazidime, metronidazole, vancomycin hydrochloride

(b) SHORT TERM GOAL: The patient’s mucus production will be thinner and only needed every 2 hours by the
end of the shift.
(c) INTERVENTIONS AND RATIONALES
a. Intervention #1: Reposition the patient every 2 hours.
i. Rationale: This may help secretions mobilize (Urden et al., 2018).
b. Intervention #2: Allow rest periods between suctioning, invasive procedures, daily care, and positioning.
i. Rationale: This helps promote energy conservation (Urden et al., 2018).
c. Intervention #3: Help the RT with ETT suctioning.
i. Rationale: This will help remove secretions (Urden et al., 2018).

(d) LONG TERM GOAL: The patient will have a respiratory rate, rhythm, and depth closer to his baseline once
he is off of the ventilator, before discharge.
(e) INTERVENTIONS AND RATIONALES
a. Intervention #1: Give scheduled antibiotics, and assure that when the cultures get back, the organisms are
susceptible.
i. Rationale: This will treat the pneumonia and pleural effusion (Urden et al., 2018).
COMPREHENSIVE NURSING CARE PLAN 17

b. Intervention #2: Contact the physician and suggest prescribing bronchodilators.

i. Rationale: This could help prevent bronchospasms and help remove secretions (Urden et al., 2018).
c. Intervention #3: Provide medication for pain management.
i. Rationale: This will help prevent the patient from minimizing chest wall expansion due to pain
(Urden et al., 2018).

(f) EVALUATIONS
a. Short term goal: Goal not met, the patient still had copious secretions suctioned every hour.
b. Long term goal: Goal expected to be met, because medication and physical assistance are being
implemented to help the patient clear his infection, and hopefully reliance on the ventilator.

2. NSG DX #2: Risk for sepsis infection related to inadequate secondary defenses, use of a corticosteroid, invasive
procedures, low white blood cell count, malnutrition, and chronic diseases.
(a) NURSING ASSESSMENT
a. Related Assessments: temperature, wound assessments, urine output/stasis, breath sounds
b. Related Labs and Tests: CBC, lactate, cultures
c. Relevant Meds: dexamethasone, filgrastim, ceftazidime, metronidazole, vancomycin hydrochloride

(b) SHORT TERM GOAL: The patient will have a stable temperature, under 100.4 degrees Fahrenheit.
(c) INTERVENTIONS AND RATIONALES
a. Intervention #1: Perform proper hand hygiene and adhere to contact precautions.
i. Rationale: This reduces the transmission of microorganisms (Urden et al., 2018).
b. Intervention #2: Collaborate with physician and dietitian to re-implement nutrition, since the patient’s
procedure that did required an NPO order is no longer scheduled for today.
i. Rationale: Nutrition should be adequate for the patient’s body and condition requirements and is
needed to prevent higher susceptibility to infection (Urden et al., 2018).
c. Intervention #3: Maintain caps on all stopcock ports and use aseptic technique when accessing lines.
i. Rationale: This helps reduce portals of entry for new pathogens (Urden et al., 2018).

(d) LONG TERM GOAL: The patient will have improved white blood cell count beyond the current level of 0.6
by time of discharge.
(e) INTERVENTIONS AND RATIONALES
a. Intervention #1: Collaborate with physician and remove ART line and CV line as soon as possible.
i. Rationale: This decreases portals of entry for new pathogens (Urden et al. 2018).
b. Intervention #2: Maintain the head of bed at 30 – 45 degrees.
i. Rationale: This helps decrease the chance of aspiration and further pneumonia infection (Urden et
al. 2018).
c. Intervention #3: Keep urinary drainage tubing and bag below the patient’s bladder level.
i. Rationale: This decreases the incidence of urinary tract infections (Urden et al. 2018).

(f) EVALUATIONS
a. Short term goal: The patient’s goal was met; the highest the patient’s temperature reached was 99.4.
b. Long term goal: Goal expected to be met, because the collaborative care and pathogen combative measures
should help improve the chance for white blood cell production and for reduction of current infections.

What is the worst possible/most likely complication to anticipate based on the primary problem?

The patient could go into septic shock, based on complications that have developed from the primary problem (Urden et

al., 2018).
COMPREHENSIVE NURSING CARE PLAN 18

What nursing assessments will identify this complication EARLY if it develops?

I will monitor the patient’s temperature, respiratory rate, blood pressure, heart rate, wounds, output, nutrition status,

fluid status, and diagnostic tests (Urden et al., 2018).

What nursing interventions will you initiate if this complication develops?

I will activate a code sepsis. I will draw labs and repeat blood cultures and get an order from the physician. I will

continue to give IV fluids and get an order to give a blous of 500 mL over 30 minutes. I will continue to give vasopressors and

provide mechanical ventilation (Urden et al., 2018).

SHIFT RESPONSE EVALUATIONS:

All physicians’ orders have been implemented that are listed under medical management. Evaluate the response of your patient
to nursing and medical interventions during your shift.

1. Has the status or your patient improved or not as expected to this point?

No, the patient’s condition has not improved. His vitals are stable, but they are getting to a level that is

close to sepsis. The patient still has the need for mechanical ventilation and all invasive lines. He still has a large

amount of secretions, and absent lung sounds on the left.

2. Do your nursing plans/goals and interventions need to be modified in any way after this evaluation assessment?
Explain:

No, I will continue to implement the same goals and interventions. The patient’s chronic and acute

conditions are compounding each other. Respiratory status, infection, adequate sedation, pain management, and

comfort can be ensured with the goals and interventions that I have been implementing.

3. What will be the most important discharge/education priorities you will reinforce with their medical condition to
prevent future readmission with the same problem? Explain:

Do not smoke, take all of your medications, be mobile, and actively cough and deep breath to prevent

further lung complications. Also, enjoy your family and find reason for motivation.
COMPREHENSIVE NURSING CARE PLAN 19

References

Ackley, B.J, Ladwig, G.B, Flynn Makic, M.B. (2017). Nursing diagnosis handbook: An evidence-based guide to

planning care (11th ed.). St. Louis, MO: Elsevier, Inc.

Malarkey, L. M., McMorrow, M. E. (2012). Saunders nursing guide to laboratory and diagnostic tests (2nd ed.). St.

Louis, MO: Elsevier Saunders.

Shields, K.M., Fox, K.M., & Liebrecht C. (2018). Pearson Nurse’s Drug Guide. Hoboken, NJ: Pearson Education,

Inc.

Urden, L. D., Stacy, K. M., Lough, M. E. (2018). Critical care nursing diagnosis and management (8th ed.).

Maryland Heights, MO: Elsevier Inc.

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