HA NOI MEDICAL UNIVERSITY

ADVANCED NURSING PROGRAM

NURSING CARE PLAN

STUDENT: Pham Thu Quynh

GROUP: 41 CLASS: Y4Q

UNIT: Intensive Care Unit

DATE OF CARE: 22/8/2018 (6th after administration)

PATIENT’S FULL NAME : Pham Đuc Thieu

ADMISSION DATE: 17/8/2018

AGE/GENDER : 67/ Male

ALLERGIES : no allergies

SOCIAL SUPPORT: His daughter-Pham Thi Thuy

Phone number: 0165319966

ADDRESS : Hai Hau- Nam Dinh

Cheif Complaints on Admission

Pain and swelling of the deltoid muscle (in the left arm)

Present history:

Before admission 10 day, he started to high fever, pain and swelling deltoid muscle (in the
left arm). He came to hospital examination, the result of CT scan he has 2 abscess next to
abdominal aorta and he is admitted Bach Mai Hospital on August 17,2018.

At 15h30 he was transferred to intensive care unit for further treatment.

His Vital sign when transferred to ICU :

Pulse: 100bpm

BP:130/60 mmHg

Temperature:38 Celcius degree

RR: 20/bpm
 He is aleart, Glasgow :14 point

Mild pale skin and mucosa

Soft belly, pressing epigastric pain 7/10

His weight : 62 kg ; height: 1.61m BMI= 23.92

Medical history:

a, patient history:

-Patient had diabetes mellitus 2 years ago, use Amlor 5mg/day

-Hypertension had 4 years ago

b, family history:

No metabolic disorder has been found.

Admitting Diagnosis and Current Diagnosis:

AD: multi-driver abscess, monitoring septicemia, hypertension, diabetes mellitus

CD: multi-driver abscess, septicemia Klebsiella Pneumoniae, hypertension, diabetes

mellitus

Focus assessment:
1. Admission condition:(17/8/2018)

 Drowsiness, Glasgow: 15

 Regular heart sounds.

 Normal lung sounds, clear vesicular, moisture rales.

 Ascites, mild distention.

 Vital signs: Pulse: 100pbm

BP:130/60mmHg

RR:20 pbm

Temperature:38oC

2. Current assessments:(22/8/2018)

- General condition:

 Alert, Glasgow 15 point.

  Skin: no hemorrhage under the skin, no cyanosis,

Membrane: pale, no hemorrhage under the skin, no ulcer

 Vital signs: BP:120/70mmHg;

Pulse: 95bpm, Temperature: 37oC, RR:19 bpm

 Blood glucose: 6:00 am: 12,3 mmol/l

(run electric injection pump with 2 unit/hours)

 Weight:61 kg ( decreased from 62kg –>61kg

- Respiratory system:

 Respiratory rate: 19bpm, normal breathing, no sore throat

 Clear vesicular, no rale, no extra lung sound

- Cardiovacular system:

 mild pale skin,mucous membrane.

 Capillary refill: <2s.

 Regular heart rhythm, heart rate: 95bpm.

 Normal heart sounds; clear T1, T2

 Blood pressure: BP: 120/70mmHg.

 Patient was injected transmission line in the right hand ( 2ndday), the
needle is clean and unobstructed

- Neurological status: normal

- Gastrointestinal system:

 Abdomen: symmetric, no tumor, no scar.

 Soft, mild acsites .

 pressing epigastic pain 6/10

 Eating by mouth (2stafter remove sonde): According to the diet of

doctor BT09

Nutrison :5times/day; porridge

 No vomiting.

 Constipation for 2 days

- Genitourinary system:
  Total amount urine: 2350ml/day

 Clear yellow urine, no foam, no sediment, no abnormal odor

- Musculoskeletal system:

 delta muscle has abscess drainage (left arm), 10 ml dark red

Significant Medical History and Co-Morbidities:

V.S. (baseline) O2 Administration

Pulse: 95 beats/minute none

Respiratory rate: 19 Tubes/Drains (Intake & Output)

times/minute
Intake: eat by mouth:500ml
Body temperature: 37C
Output : urine 2350 ml
Blood pressure: 120/ 70mmHg
Drain:10ml

Total:2360ml/day

Intravenous Therapy

Antibiotic powder

Sites right branchial vein

Status stable
Capillary blood glucose

Time/date 9:00(21/8) 12:00 15:00 18:00 21:00 24:00 3:00(22/8) 6:00

Result 11.2 12.4 11.2 11.3 11.2 12.2 11.7 12.3

Insulin 2 2 2 2 2 2 2 2

(unit/hours)

Laboratory test

LABORATORY REFERENCE Admission

RATIONALE/EXPLANATION
TEST VALUE value
(ABNORMAL VALUES ONLY)
RANGES

WBC (21/8/2018) 4.0 – 10.0 Gl 9.3

Neutrophils % 45 – 75% 85.6
Lymphocytes % 25 – 45% 8.5 Infection

Monocytes % 0 – 8% 5.6
Eosinophils % 0 – 8% 0.3
Basophils % 0 – 1% 0.0
Neutrophils # 1.8 – 7.5G/l 8.0
Lymphocytes # 1.0 – 4.5G/l 0.8
Monocytes # 0 – 0.8G/l 0,5
Eosinophils # 0 – 0.8G/l 0,0
Basophils # 0 – 0.1G/l 0,0
RBC 4.5-5.9 T/l 3.23

HGB 135 – 157g/l 93 risk of anemia

HCT 0.4-0.53 l/l 0,282 risk of anemia

MCV 80 – 100Fl 87.4

MCH 26 – 34pg 28.7
MCHC 315 – 363g/l 329
Platelets 150 – 400G/l 174
RDW 10 – 15% 13.5
MPV 5 – 20fL 9.9
Basic
Metabolic
Panel:
Na 136 – 145 131
mmol/l
K 3.5 – 5.1 mmol/l 3.4
Cl 98 – 111 mmol/l 100
Albumin 35-52 g/l 30.1
Total Bilirubin <17.1 µmol/l 11.5
Total protein 66-87g/l 65
Ure 3.2-7.1 mmol/l 4.6 reliable index for assess
kidney function
Creatinine 63.6-110.5 57
µmol/l
HDL_C >=1.68 mmol/l 0.85
LDL-C <=3.4 mmol/l 2.65
Total cholesterol <5.2 mmol/l 5.30
Triglyceride <2.26 3.96
Coagulation: ‘

Prothombin S 13
PT % 70 – 140 % 77
PT-INR 1.19
APTT s 31.2
Fibrinogen 2 – 4g/l 6.67 increased -> can cause
embolus
Von-Kaulla >60 minute >60
method
D-Dimer <0.48 mg/l FEU 4.476
Immune:

FT3 1.3-3.1 nmol/l 0.61

FT4 12-22.0 pmol/l 11.7
TSH 0.27-4.2 uU/mL 2.050
Pro-calcitonin <0.55 ng/L 11.590
Pre- Albumin 0.2-0.4 g/l 0.08
Transferrin 200-400 mg/dl 93

Urine test

LEU (-) 70 cells/ul

PRO (-) 1.0 g/l

SG 1.003-1.030 1.022

GLU (-) 28 mmol/l

NIT (-) NEG

PH 5,5-6,5 6.5

KET (-) 1.5 mmol

UBG 3.2-16 umol/L 16

ERY (-) 200 cells/ul

BIL (-) Small

A/C normal 17.0 mg/mmol

OTHER DIAGNOSTICS OR SIGNIFICANT INFORMATION (x-rays, MRI, other

studies):

- microbiological assay (20/8):

blood: Klebsiella pneumoniae – 15000 CFU/ml

 pus: not see the fungus

-ultrasound:

Right kidney cyst images, prostatic hypertrophy

-CT scan:

abscess next to abdominal aorta lower part of the renal artery, atherosclerosis and
calcified aortic system of pelvic, abscess of right lumbar-pelvic muscle, multifocal
lesions liver parenchyma, kidneys and lungs, large liver.

abscess: tricep brachii muscle

abscess: lung parenchia both of side

NURSING PROCESS

Nursing diagnosis1: Risk for infection

- he has abscess, septicemia

-Patient has surgical incision abscess in the left arm , 5cm, 3 rdday and the sutures is
dry, the would is red, swollen, hotter than other hand, pain

-foot drainage has fluid

Nursing Intervension Rational

1. Assess client for a possible source of
infection: open wounds, cellulitis, drain,
hospital inviroment,IV
2.check vital sign 3hours 1time, special
temperature, note temperature trends
and observe for shaking chills and
profuse diaphoresis
3. Teach proper hand washing using
antibacterial soap before and after each
1. The most common causes of sepsis
are respiratory tract. Other causes of
hospital-acquired sepsis are the use of
intravascular devices.
2. Fever 38.5°C-40°C is the result of
endotoxin effect on the hypothalamus
and pyrogen-released endorphins.
Hypothermia lower than 36°C is a grave
sign reflecting advancing shock state,
decreased tissue perfusion, and failure of
the body’s ability to mount a febrile
response. Chills often precede
temperature spikes in the presence of
generalized infection.
3. Hand washing and hand hygiene
care activity
4. Maintain sterile technique when
changing dressings, and providing site
care, such as an invasive line
5. Investigate reports of pain out of
proportion to visible signs.
6. Inspect wounds and sites of invasive
devices daily, paying particular attention
to parenteral nutrition lines. Document
signs of local inflammation and infection
and changes in character wound
drainage, or urine.
7. Encourage or provide frequent position
changes, deep breathing, and coughing
exercises
8. Wear gloves and gowns when caring
for open wounds or anticipating direct
contact with secretions or excretions.
9. Monitor laboratory studies, such as
WBC count with neutrophils and band
counts
Desired Outcomes
Client will achieve timely healing; be free of purulent secretions, drainage, or
erythema; and be afebrile.
Nursing diagnosis 2:Risk of hyperthermia
-Body temperature elevated above the normal range, patient has been fever
lessen the risk of cross-contamination.
Note: Methicillin-resistant
Staphylococcus aureus (MRSA) is most
commonly transmitted bacteria via direct
contact with health care workers who
unable to wash hands between client
contacts.
4. Medical asepsis inhibits the
introduction of bacteria and reduces the
risk of nosocomial infection.
5. Pressure-like pain over an area of
cellulitis may indicate developing of
necrotizing fasciitis due to abscesses
necessitating prompt intervention
6. Clinical signs, such as local
inflammation or phlebitis, may provide
type of primary infecting organism (s), as
well as early identification of secondary
infections.
7. Good pulmonary toilet may reduce
respiratory compromise.
8. Prevents spread of infection and cross
contamination.
9. when WBC count is markedly
decreased, calculating the absolute
neutrophil count is more pertinent to
evaluating immune status
before surgery (max temperature:40oC)

- he has a lot of abscess, septicemia

Nursing Intervention Rational

1. Monitor client temperature–degree 1. Temperature of 102°F to 106°F

and pattern. Note shaking chills or
profuse diaphoresis.
(38.9°C- 41.1°C) suggest acute
infectious disease process. Fever pattern
may help in the diagnosis. and
intermittent curves or fever that returns to
normal once in 24-hour period suggest
septic episode, septic endocarditis, or
tuberculosis (TB). Chills often precede
temperature spikes

2. Room temperature and linens should

2. Monitor environmental
temperature. Limit or add bed linens,
as indicated.
3. Provide tepid sponge baths. Avoid
use of alcohol
be altered to maintain near-normal body
temperature
3. Tepid sponge baths may help reduce
fever. The use of alcohol may cause
chills, elevating temperature, and skin
dehydration

4. Antipyretics reduce fever by its central

4. Administer antipyretics accodding
action on the hypothalamus; fever should
prescribed by a doctor
be controlled in clients who are
neutropenic or asplenic

Desired Outcomes

 Client will experience no associated complications.

 Client will demonstrate temperature within normal range and be
free of chills

Nursing diagnosis 3: Risk for Decreased Cardiac Output related to

hypertention

- high blood pressure: at 21:00 BP:180/90 mmHg,

22:00 BP:160/90 mmHg

 24:00 BP: 140/90 mmHg
Nursing Intervention
1. Monitor and record BP. Measure in
both arms and thighs three times, 3–5
min apart while patient is at rest, then
sitting, then standing for initial evaluation. hypertension is classified in the adult as
Use correct cuff size and accurate
technique
2. Observe skin color, moisture,
temperature, and capillary refill time
3. Note dependent and general edema.
4. Evaluate client reports or evidence of
extreme fatigue, intolerance for activity,
sudden or progressive weight gain,
swelling of extremities, and progressive
shortness of breath.
5. Monitor response to medications to
control blood pressure.
Rational
2. Comparison of pressures provides a
more complete picture of vascular
involvement or scope of problem. Severe
a diastolic pressure elevation to 110
mmHg; progressive diastolic readings
above 120 mmHg are considered first
accelerated, then malignant (very
severe). Systolic hypertension also is an
established risk factor for
cerebrovascular disease and ischemic
heart disease, when diastolic pressure is
elevated.
2. Presence of pallor; cool, moist skin;
and delayed capillary refill time may be
due to peripheral vasoconstriction or
reflect cardiac decompensation and
decreased output.
3. May indicate heart failure, renal or
vascular impairment
4. To assess for signs of poor ventricular
function or impending cardiac failure.
5. Because of side effects, drug
interactions, and patient’s motivation for
taking antihypertensive medication, it is
important to use the smallest number
 and lowest dosage of medications.

Desired Outcomes

 Participate in activities that reduce BP/cardiac workload.

 Maintain BP within individually acceptable range.

 Demonstrate stable cardiac rhythm and rate within patient’s normal

range.

 Participate in activities that will prevent stress (stress management,

balanced activities and rest plan).

Nursing diagnosis 4: Risk for Unstable Blood Glucose

Patient has fasting blood glucose levels of more than 10 mmol/l

Nursing Intervention Rational

1. Assess for signs of hyperglycemia. 1. Hyperglycemia results when there is

2. Assess blood glucose level 3 hours for
1 time
3. Assess feet for temperature, pulses,
color, and sensation.
an inadequate amount of insulin to
glucose. Excess glucose in the blood
creates an osmotic effect that results in
increased thirst, hunger, and increased
urination. The patient may also report
nonspecific symptoms of fatigue and
blurred vision.
2. Blood glucose should be between 140
to 180 mg/dL. Non-intensive care
patients should be maintained at pre-
meal levels <140 mg/dL.
3. To monitor peripheral perfusion and
neuropathy.

5. A patient with type 2 DM who uses

5. Monitor for signs of hypoglycemia.
insulin as part of the treatment plan is at
increased risk for hypoglycemia.
Manifestations of hypoglycemia may vary
among individuals but are consistent in
the same individual. The signs are the
result of both increased adrenergic
 activity and decreased glucose delivery
to the brain, therefore, the patient may
experienced tachycardia, diaphoresis,
dizziness, headache, fatigue, and visual
changes

Desired outcomes

Patient has a blood glucose reading of less than 180 mg/dL (<10 mmol/l); fasting
blood glucose levels of less than <140 mg/dL(< 7,5 mmol/l); hemoglobin A1C level
<7%.

Nursing diagnosis 5: Deficient Knowledge

-Absence, deficiency of cognitive information related to a disease .

- Cognitive limitation

Nursing Intervention Raitional

1. Review disease process and future
expectations.
2. Review individual risk factors, mode of
transmission, and portal of entry of
infections.
1. Discussing the disease and clinical
expectations provides a knowledge base
from which client can make informed
choices.
2. Awareness of means of infection
transmission provides an opportunity to
plan for and institute preventive
measures.

3. Discuss need for a good nutritional 3. Good nutrition is necessary for optimal
intake or balanced diet. healing, immune system enhancement,
and general well-being.

4. Sufficient and appropriate information

4. Provide information about drug promotes understanding and enhances
therapy, interactions, side effects, and compliance with treatment or
the importance of compliance with the prophylaxis, and reduces the risk of
treatment regimen. recurrence and complications
5. Identify signs and symptoms requiring
medical evaluation: persistent high fever,
increased heart rate, syncope, rashes of
unknown origin, unexplained fatigue,
anorexia, increased thirst, and changes
in bladder function.
5. Early recognition of developing
infection will allow a timely intervention
and reduces the risk of life-threatening
complications.

Desired Outcomes

 Client will verbalize understanding of disease process, prognosis, and

potential complications.

 Client will verbalize understanding of therapeutic needs.

 Client will participate in the treatment regimen.

 Client will initiate necessary lifestyle changes.

 Client will correctly perform necessary procedures and explain the rationale
for the actions.

Medicine

Name of drug Dose and route Effects of drugs Side effects of drugs
administration
Meronem 1g 3 vial-divided into 3 -treatment of infections: -digestive disorders
times
Septicemia; Meningitis; -seizures, convulsions
Intravenous Skin and skin structure
infusion: 1vial + infections; -pseudomembranous
100ml NaCl 0.9% Gynecological colitis
infections; Infections in
30 ml/h -allergy
the abdomen; Urinary
tract infections;
22:30 6:00 14:00
Pneumonia and
hospital pneumonia

Selemycin 5 vial
250mg/2ml
Intravenous
infusion + 100ml
NaCl 0.9%

100ml/h ; 22h

Lovenox 1 pump -treat or prevent a type -nausea, diarrhea

40mg/0.4ml of blood clot called
Subcutaneous deep vein thrombosis -alergic
injection (DVT)
-anemia
15:00 -prevent blood vessel
complications in people -confusion
with certain types of
angina (chest pain) or -pain, bruising,
redness, or irritation
heart attack.
where the medicine
was injected.

Concor 5mg 1/2 tablet Hypertension. Hypotension,

bradycardia, edema,
Oral Chest pain. edema, dyspnea,
anorexia,
15:00 Heart failure.
gastrointestinal
disorders, cold hands
and feet, fatigue,
dizziness, headache,
 skin allergies

Kali clorid 40mg 2 pack Prevention and - allergic: hives;

treatment of difficult breathing;
Oral hypokalaemia swelling of your face,
lips, tongue, or throat.
23:00
- nausea, vomiting,
diarrhea;

-gas, stomach pain; or

-the appearance of a
potassium chloride
tablet in your stool.

Pantoloc 40mg 1 tablet - used in the treatment - Headache

of stomach ulcers,
Oral gastroesophageal -Altered sense of taste
reflux disease (GERD)
18:00 -Runny Nose and
and other acidity- Cough
related disorders.
-Diarrhea
-decreases the acid
produced in the -Nausea or Vomiting
stomach and helps in
promoting healing of -Unusual tiredness and
ulcers weakness

-Skin Rash

-Anorexia

Lipitor 10mg 1 tablet - treatment of -Constipation,

Hypercholesterolemia flatulence,
Oral and mixed blood lipid gastrointestinal
disorders. disorders, abdominal
20:00
Hypertriglyceridemia. pain
Beta-lipoprotein
disorder -muscle weakness, dry
skin, itching,
palpitations.