Running head: NURSING CARE PLAN 1

Nursing Care Plan

Jordan Polite
Trent University
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Nursing Report

Mrs. Newman is an 84yo female who was sent to the ER via ambulance from Shady Acres, a
long-term care facility.
- Recent confusion and agitation
- Decreased intake of food and fluids
- Incontinent of urine
- Progressive decreased LOC since last night
- Patient responding to pain with moan
- Pulse 128 beats/min, BP 90/50, RR 20, Temp 38. 40 Celsius
- Foley catheter insitu draining moderate amount of dark urine with small amount of
visible pus
- Medications include Hydrochlorothiazide, Arthrotec, and Metoprolol
- Her medical history includes hypertension and osteoarthritis
- The patient has a DNR code status
Focused Assessment
ABCs
A – Patent
B – Normal rate and depth, no use of accessory muscles
C – Facial flushing d/t high temp, pallor d/t low BP, ? infection, diaphoretic d/t infection and
febrile
VS
HR – 128 tachycardia d/t hypotension, ? infection, ? med adherence (beta blocker)
BP – 90/50 hypotension d/t dehydration or ? infection, or thiazide diuretic
RR – 20, normal
T – 38.4 febrile d/t ? infection
SpO2 – 84% on RA: hypoxia d/t hypotension, ? infection
Pain – Pt only responding with moans when sternal rub initiated, bilateral lower flank and
suprapubic area palpation also eliciting moans d/t ? urinary tract infection
- Pt unable to provide pain score out of 10 at this time d/t dec LOC
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CNS
- Pt is not alert or oriented d/t hypoxia r/t ? infection and/or ? dehydration
- Pt semi-conscious d/t hypoxia
- Pupils 3mm, bilaterally equal, responsive to light
- GCS 9 (eyes respond to pain – 2, incomprehensible sounds – 2, localizes pain to
stimulus – 5) d/t hypoxia
- Recent agitation and confusion d/t hypoxia
CVS
- HR 128 apically: Tachycardic d/t hypotension
- Amplitude: Bounding d/t compensation for hypotension r/t ? infection and/or ?
dehydration
- BP 90/50: Hypotension d/t ? dehydration or ? infection
- MAP = 63 low d/t ? infection and/or ? dehydration
- Pulse pressure = 40
- No JVD
- Heart rhythm regular
- Radial pulses equal bilaterally
- Radial pulses equal to apical pulse bilaterally
- Apical – S1 = S2, no S3 or S4 present
- Cap refill 4 seconds d/t hypotension r/t ? infection and/or ? dehydration
- Unable to assess for postural hypotension d/t dec LOC
- No response observed when palpating calves
- No edema noted
- PPP

Resp
- RR 20, normal rate and rhythm
- SPO2 84% on room air: Hypoxia d/t ? infection and/or ? dehydration
- Inspection: Symmetrical chest rise
- No accessory muscle use
- No barrel chest noted
- Auscultation: A/E decreased to lower lobes bilaterally d/t advanced age, hypoxia
o A/E equal and clear to upper and middle lobes
- Unable to assess for SOB or dyspnea d/t dec LOC
- No adventitious sounds
- No cough
- Pt has no history of smoking
GI
- Inspection: ABD round, symmetrical
- Palpation: ABD soft, non-distended
o ABD upper quadrants non-tender
o ABD lower quadrants elicit moan when palpating d/t ? UTI
- Auscultation: BSP x 4 quadrants
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- LBM 2 days ago

- Loss of appetite in recent days: Anorexia d/t dec LOC r/t ? infection
- Unable to assess nausea at this time d/t dec LOC
- No vomiting

GU
- Pain upon palpation of flank and suprapubic area d/t ? infection
- Foley catheter insitu d/t recent incontinence of urine and dec LOC
- Foley draining 35 ml/h d/t kidney hypoxia
- Urine is dark d/t ? infection and/or ? dehydration
- Small amount of visible pus in urine d/t ? infection
- Hematuria d/t ? infection
- Urine has foul odor d/t ? infection

Integumentary
- Mucous membranes dry d/t ? dehydration
- Diaphoretic d/t febrile

Labs/Diagnostic Imaging
- CBC with differential
- Blood culture x2
- Blood glucose
- Extended electrolytes – Na, K, Cl, Mg, Ph, Ca
- Clotting factors – PT, PTT, INR
- ABGs
- BUN and creatinine
- Urinalysis
- Urine culture and sensitivity
- Urine osmolality
- Specific gravity
- KUB
- Ultrasound
- Abdominal CT scan
- 12-lead ECG
- Cardiac markers – troponin and CK
- Serum lactate
- Serum C-reactive protein
- LFTs – ALT, AST, ALP, bili
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Health history
 S – confusion, agitation, altered LOC, tachycardia, hypotension, febrile, facial
flushing, dec urinary output, visible pus in catheter, dark urine, cap refill 4 sec, flank
and suprapubic pain, dry mucous membranes, dec A/E to lung bases, GCS – 9
 A – NKA
 M – Hydrochlorothiazide, Arthrotec, Metoprolol
 P – Hypertension, osteoarthritis
 L – 2 days ago
 E – Over the past few days - Increasing confusion and agitation, dec food and fluid
intake, incontinence of urine, progressing dec LOC

- Questions for family:

o What is the pt’s baseline cognitive function?
o Has the pt been taking their meds?
o Does the pt have any allergies?
o Does the pt have a history of UTIs

Medications
- Hydrochlorothiazide (Urozide) – thiazide diuretic for hypertension
- Arthrotec:
o Diclofenac (Voltaren) – NSAID for osteoarthritis
o Misoprostol (Cytotec) – Antiulcer to prevent gastric mucosal injury from
NSAID use in high risk patients
- Metoprolol (Betaloc) – beta blocker for hypertension

Nursing Diagnosis

1. Risk for ineffective tissue perfusion r/t hypotension; secondary to infection – AEB dec

LOC, dec cap refill, MAP = 63, hematuria, pus in catheter

2. Risk for fluid volume deficit r/t dehydration secondary to recent dec in food and fluid

intake, and dec LOC – AEB low urine output, dark urine, dry mucous membranes

3. Risk for impaired skin integrity r/t dec LOC and recent dec in food and fluid intake –

AEB recent agitation, confusion, progressive dec in LOC, incontinence of urine

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Nursing Interventions
- Maintain airway
- Hand hygiene
- Wear proper PPE
- Monitor vital signs Q15mins (HR, BP, T, RR, SPo2)
- Administer acetaminophen (Tylenol) rectal, for fever
- Administer IV fluids (normal saline) 500 bolus and 100 mL/h
- Administer antibiotics (start with broad spectrum)
- Titrate O2 for SPO2 of greater than 94%
- GCS Q30mins
- Continuous ECG
- Administer vasopressors (Norepinephrine, Vasopressin)
- Communicate with and educate family
- Update MD
- Flush Foley catheter
- Intubation and mechanical ventilation prepared if necessary
- Monitor hemodynamic parameters – CVP, MAP, PAOP
- Monitor ins and outs
- Monitor bowel sounds Q4h
- Reposition pt every 1-2 hours
- Maintain 2 large-bore IV sites
- Assess lung sounds for crackles and other signs of fluid overload
- Administer pain medication Hydromorphone (Dilaudid)
- Apply Vaseline to lips to prevent cracking

Ethical Considerations
One ethical consideration that I think could directly impact this patient involves her

DNR order. DNR orders can be very complicated depending on the circumstances of the

situation. According to Huang, Chuang, Tsai, Ko, & Yu (2016), DNR orders increase

mortality among patients with sepsis and other, similar health problems. While there may be

many possibilities behind this phenomenon, one key issue that Huang et al. (2016) highlighted,

was that DNR orders could be interpreted as a reason to withhold therapeutic or aggressive

measures beyond CPR.

As nurses we must continue to provide the highest quality of care that we can, for as

long as we can. The care that we provide should not be different for a patient that has a DNR
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order and a patient that does not, until the patient codes. If this was my patient I would

continue to follow best practice guidelines and treat this patient as I would any patient. I would

also advocate for my patient if necessary, if I felt that other members of the care team were

treating her differently because of the DNR order.

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References

Huang, C., Chuang, Y., Tsai, Y., Ko, W., & Yu, C. (2016). High mortality in sever sepsis and

septic shock patients with do-not-resuscitate orders in east Asia. PLoS ONE, 11(7), 1-11.

doi: 10.1371/jo

Lehne, R. A., Rosenthal, L. D., & Burchum, J. R. (2013). Pharmacology for Nursing Care

(9thed.). London: Elsevier Health Sciences.

Lewis, S.L., Bucher, L., Heitkemper, M.M., Harding, M.M., Barry, M., Lok, J., Tyerman, J., &

Goldsworthy, S. (2019). Medical-Surgical Nursing in Canada: Assessment and

Management of Clinical Problems (4th Canadian edition). Toronto, ON: Elsevier.