Clinical Care Plan Essay Assignment Paper
Student: _________________________________ Date: ______________________________
Submission of clinical care plan on due date (5 Points)
Instructor: ______________________________ Clinical Course: ______________________
Client’s Code Name: Mr. Daniel’s Age: 34 years Gender: Male
Primary Medical Diagnosis: Sepsis
Secondary Medical Diagnoses: Blood infection
Present Surgery (if applicable): N/A Date of Surgery: N/A
Allergies and Symptoms They Cause: No known Drug Allergies
Height: N/A Weight: N/A
Code Status: N/A
Section I
General Data, Health History, and Review of Systems
( 10 Points)
Biographical Data:
Mr. Daniels is a 34-year-old Caucasian male who is a businessman He is married and has three children. He lives in North Carolina along with his wife and children. He is polite and charming.
Chief Complaint:
I do not have any energy, and I feel very tired, weak and have a great urge to sleep all the time. I also feel a bit restless Clinical Care Plan Essay Assignment Paper.
History of Present Illness (Detailed):
Mr. Daniels presents to the facility complaining of fatigue, malaise, and fever that persisted over the past three weeks. He has been taking ibuprofen and acetaminophen every 4-6 hours at home and he reports that they help a little.
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Past Medical/Surgical and Injury History:
Reynard’s disease
Pre-hypertension
Sociocultural History (alcohol, tobacco, drugs, ADLs, marital status, children, religion, culture, ethnic group, and education):
Mr. Daniels is a Caucasian man who is married and has 3 children. He smokes one pack of cigarettes a day but denies alcohol or illicit drug use. He is a high school teacher
Spiritual Well-Being:
Mr. Daniels.is a Christian man. He prays every day before going to bed.
Family History of Illness:
Mr. daniels has a brother with hypertension and a diabetic sister. Both parents are alive and healthy.
Immunization History:
All immunizations are up to date.
Developmental Stage in Life:
Intimacy vs. Isolation
Description of Procedures (Surgeries) Performed this Admission:
None
Review of Systems – brief history of each system and use abbreviated format, not complete sentences
General: Mr. Daniels presents symptoms such as fever, fatigue, and malaise, general weakness and tired and the urge to rest/sleep.
Psychiatric: Mr. Daniels present mal-adaptation of perception, manifesting through his confession that he thought coming to the hospital would have helped, although perceives that if the practitioner nurse guesses he is okay and he can go home.
Skin, hair, and nails: No rash, itching, or hives. Normal full hair color.
No clubbing nails Clinical Care Plan Essay Assignment Paper
Lymph nodes: No swollen lymph nodes
HEENT (head, eyes, ears, nose, mouth, throat): No difficulty with hearing, sinus problems, post-nasal drip, runny nose, ringing in ears, loose teeth, mouth sores, sore throat, nosebleeds, ear pain. Pain on the laceration site on the forehead
Neck: Carotids 2+ equal without bruits
Blood: Mr. Daniels presents normal blood pressure following Nurse Inmer’s repeated readings of 130/80 mm Hg.
Breasts: No breast pain, no inflammation, nipple discharge or erythema.
Cardiovascular: Mr. Daniels presents a high heart rate of 110, which is a high resting heart rate and suggests he has tachycardia
Respiratory: No cough, shortness of breath, difficulty breathing, or wheezingGI: Positive for Abdominal. No vomiting, nausea, heartburn, difficulty swallowing, diarrhea, or blood in stool.
GU: Frequent urination. No painful urination, prostate problems, bladder problems, or incontinence.
Musculoskeletal: no joint or muscle pain. No pain radiation
Neurologic: No seizures, weakness. Mr. Daniels experiences dizziness
Endocrine: No frequent urination or thirst. No intolerance to heat or cold.
Section II
In this section, the student must address a description of the disease process including etiology, pathophysiology, signs and symptoms and standard treatment including medication, surgery, etc. (This section should be used to describe the textbook explanation of the disease and compare it with the patient’s picture of his/her disease condition. Attach a reference page at the end of care plan ) References done in APA Format (5 Points) Clinical Care Plan Essay Assignment Paper
Pathophysiology of Disease Process
Sepsis is a life-threatening health condition, arising from the body responses upon the existence of a infectious insult triggering a localized inflammatory reactions. The inflammatory The inflammatory reaction arises from the release of cytokines, such as tumor necrosis, neutrophils, macrophages and interleukins. Upon their release, the cytokines activates and results to the coagulation of the extrinsic cascade (Bhan et al., 2016). As a result, there is the inhibiting of fibrinolysis. These processes are overlapping and triggers microvascular thrombosis, which results to organ dysfuction. On the other hand, activation of coagulation system results to endogenous anticoagulant’s consumption, an aspect that enables the development of miscrovascular coagulation. Collectively, the inflammatory and anti-inflammatory mediator’s results to the patients experiencing sepsis, and their continued presence can result to poor outcomes such as low recovery Clinical Care Plan Essay Assignment Paper.
Patients suffering from the condition exhibits certain patho-physiological changes, with the main being fever, tachycardia, excess sleepiness and fatigue. In some instances, the patient’s blood pressure will remain normal. However, the patho-physiological changes are bound to vary with the variation in the severity of the condition. For instance, sever sepsis levels such as in septic shock, decreased alertness or confusion are some of the most common patho-physiological changes the patients is likely to experience.
Classic Signs and Symptoms of Disease Process
Some of the classic signs and symptoms associating with the sepsis are fever, difficulty in breathings and fast heart rate, dizziness and fatigues. In some instances, the patients have low body temperature, low blood pressure, breath shortness, organ dysfunction, low urine output, delirium and mental confusion.
Section III
Physical Assessment
(15 Points)
Physical Assessment:
Vital Signs (T, P, R, BP, SPO2)
Blood pressure (113.80 mm Hg), Temperature (101 ºF), Heart rate (110 bpm) , Respiratory rate (18) and Pulse rate ( ox 95%)
General Appearance
Mr. Daniels appears weak, especially through his talking. He appears confused and with altered perception
Psychiatric
Mr. Daniels has a mal-adaptation of perception, manifesting through his confession that he thought coming to the hospital would have helped, although perceives that if the practitioner nurse guesses he is okay and he can go home.
HEENT: PERRLA, no rhinorrhea, clear ears, hoarseness in voice erythema to throat. No ear pain, no congestion or nasal discharge.
Neck – No swollen lymph nodes, no mass or tenderness. Neck is symmetrical and supple
Breasts and Lymph Nodes- No nipple discharge or erythema. No swollen lymph nodes
Pulmonary: Lungs clear, denies shortness of breath, equal chest expansion
Cardiovascular: Mr. Daniels has a high heart rate of 110, which is a high resting heart rate and suggests he has tachycardia
Skin and Nails- Intact, no dryness or rashes. No clubbing of the nails or pain
Abdomen- Abdomen is soft, non-tender, non-distended, bowel sounds present all quads Clinical Care Plan Essay Assignment Paper
Genitourinary: Voids clear yellow urine via urinal without difficulty
Pelvic and Rectal: No problems noted
Extremities: extremities are symmetrical in size and length.
Musculoskeletal: normal ROM, no joint pain or muscle aches
Neurological (DTR’s, reflex grading, cranial nerve evaluation): Alert and oriented x4, full range of motion all extremities, complains of dizziness
Incisions: No incisions. Skin is warm, dry. No lesions or rashes
Drains: No drains noted
Diet/Nutrition: patient is on regular diet
IVs: None
Intake and Output: Intake and output are within normal ranges
Pain assessment: a score of 1 in a scale of 1-10
Fall Risk Assessment. Fall risk patient
Pressure Ulcer Risk Assessment: No risk for pressure ulcer
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Section IV
Diagnostic Data
(5 Points)
Inlcude pertinent diagnostic tests, including labs, EKG, and X-Rays
| Diagnostic Tests | Patient’s value | Normal Range | Inference(why is this patients value abnormal) |
|
Blood pressure |
113.80 mm Hg | 120/80 mmHg | Mr. Daniels has low blood pressure, which more often arises from reduced blood volume, and can also exist whenever the patient is suffering from sepsis |
| Temperature
|
102.5 ºF | 98.6°F (37°C) | Mr. Daniels has a temperature above the normal one, a clear indication of fever, which arises from either an illness or infections such as sepsis. |
| Heart Rate | 110 bpm | 60-100 beats per minute | Mr. Daniels has high heart rate, often called sinus tachycardia a condition where the patient has a more faster-than-usual heart rhythm. Mr. Daniels has high heart rate arising from fever- a major cause for sinus tachycardia. |
|
Pulse rate |
Ox 95% | Ox 96-99% | Mr. Daniels has a slight lower pulse rate a clear indicating that his blood is carrying inadequate oxygen, although by a small portion from the expected amount. Such may arises from his low-blood pressure relative causes like sepsis Clinical Care Plan Essay Assignment Paper. |
|
Respiratory rate |
18 | 12-20 breaths per minute | Mr. Daniels has a normal respiratory rate. |
| Blood culture
|
No results displayed | Negative results without any bacteria or fungi found | N/A |
| Complete Blood Count ( CBC) test
|
No results displayed | N/A | N/A |
|
Lactate blood test |
7 mmol/L | 0.5-1 mmol/L | Mr. Daniels has elevated lactate level, which more often leads to lactic acidosis. Mainly, lactic acidosis arises when the patient has a condition resulting to difficulty in breathing enough oxygen. Sepsis is one of the main causative condition for lactic acidosis, with others being severe anemia, congestive heart failure and respiratory failure. |
|
Chem 7 test |
No results displayed | N/A | N/A |
| Arterial Blood Gas (ABG) test
|
No results displayed | N/A | N/A |
| Lactic Acid test
|
No results displayed | N/A | N/A |
Section V
Treatments and Procedures
List all treatment and procedure interventions/nursing actions dependent (physician initiated) and independent (nursing initiated) performed during your clinical experience.
( 5 Points)
| Treatments and Procedures | Day & Times | Rationale |
| Maintain activity restrictions (bedrest or chair rest); schedule periods of uninterrupted rest; assist patient with self-care activities as needed. | As needed | This promotes health and well-being which are essential to relieving fatigue and dizziness. |
| Monitor heart rhythm and pulse. Take note of dysrhythmias. | As needed | Tachycardia happens because of the activation of the sympathetic nervous system relative to the reaction to stress and to account for relative hypotension and hypervolemia. Due to hypoxia, acid-base and electrolyte deficit, and low-flow ischemia condition, cardiac dysrhythmias may occur. |
| Assess the rate of respiration, quality, and depth. Take note of chronic dyspnea onset. | Three times a day | Increased respirations, and hypoxia, fatigue, and fever, due to the immediate impacts of endotoxins on the respiratory site in the brain. When respiratory insufficiency progresses, respirations becomes shallow, leading to acute respiratory failure risk. |
Section VI
Teaching and Health Promotion
( 5 Points)
List client’s teaching Needs/Knowledge Deficits, such as teaching about a new diet, reasons for being NPO, reasons for wearing elastic stockings, etc.
- Educate and encourage Mr. Daniels to take the right balanced diet, rich in Vitamins( A,C &E) , Zinc , Iron and Protein to boost his immune system and attenuate lean body mass which collectively promote his recovery
- Educate Mr. Daniels on some of the main concepts of sepsis, such as what sepsis is, its effect on his vital body organs like brain, lungs and kidney. When doing so, uses the layman’s terms when avoiding the use of medical jargons. Such will help in addressing any knowledge deficit on sepsis by the patient and sepsis simplified patho-physiology
- Inform Mr. Daniels on the details relative to his prescribed medication such as the benefits, possible side effects, risks and appropriate use, in relation to treating sepsis. Doing do increases the patient understands of the prescribed medication, their purpose, possible adverse events to watch out for.
- Assess Mr. Daniels’ readiness to learn and any misconception he may be possessing that would hinder effective learning and proper use of the prescribed medications. Some of the sepsis relative misconceptions are poor lifestyle habits and diagnosis denial. Doing so helps in addressing Mr. Daniels mental status and cognition to sepsis, as well as helping him overcome the possible learning blocks.
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- Review and educate Mr. Daniels on proper hand hygiene, outstanding environmental cleanliness and overall personal hygiene. Doing so helps in lessening the chances for Mr. Daniels exposure to pathogens that may either increase the severity of the infections or halt his quick recovery Clinical Care Plan Essay Assignment Paper.
Section VII
(5 Points)
List of Nursing Diagnoses (Minimum of 5) Use your assessment of your client’s human needs to write your nursing diagnoses. Actual and Potential deficits and wellness diagnoses are expected. Your nursing diagnoses must be substantiated by your health assessment of your client.
| Human Needs | Nursing Diagnoses
(Circle Selected Nursing Diagnoses) |
Nursing Diagnoses Statements |
| Oxygenation
1. Perfusion (Cardiac) 2. Acid Base Balance 3. Ventilation 4. Diffusion |
Decreased Cardiac output
Tissue perfusion, altered (specify) renal, Cerebral, cardiopulmonary, gastrointestinal, peripheral |
Risk for ineffective tissue perfusion as evidenced by reduced blood oxygen supply due to breathing difficulties |
| Fluid & Electrolytes Balance
1. Acid Base Balance 2. Metabolism 3. Intracranial Regulation |
Liquids, excess volume Liquids, Volume Deficit Liquids, high risk of volume deficit Body temperature: high risk of impaired Hypothermia Hyperthermia Ineffective Thermoregulation |
Risk for deficit of fluid volume as evidenced by fluid diarrhea and improper fluid shifts arising from vascular tissues’ interstitial
Risk of hyperthermia as evidence by the vasoconstriction of the patients’ blood vessels and an increase in metabolic rate.
|
| Elimination | Constipation Subjective Constipation Chronic Constipation Diarrhea Fecal Incontinence Urinary, impaired elimination Urinary incontinence: stress Urinary Incontinence: reflects Urinary Incontinence: emergency Urinary Incontinence: Functional Urinary Incontinence: total Urinary, retention Self-care, deficit: use the potty / toilet
|
Risk of urinary functional incontinence as evidence by Kidney’s malfunction arising from patient’s dehydration and the constriction of his blood vessels |
| Nutrition
1. Energy 2. Cellular structure and function 3. Failure to Thrive 4. Metabolism |
Nutrition, altered: excess Nutrition, altered: by default Nutrition, potential alterations: excess Self-care, deficit: feeding Swallowing, impaired Ineffective Breastfeeding interrupted breastfeeding Effective Breastfeeding Infant Feeding ineffective pattern |
Risk for imbalanced nutrition and less than the required body requirements as evidenced by vomiting, increase in metabolism and nausea
|
| Sleep | Sleep pattern disturbance | Risk of sleep pattern disturbance as evidence by either delirium, excess sleepiness, poor sleep and sleep disruptions |
| Mobility | Disuse, high risk of syndrome Physical mobility, disorder Peripheral Neurovascular, high risk of dysfunction Activity intolerance Activity, high risk of intolerance Self-care, deficit: dressing / grooming |
|
| Sensation and Cognition
1. Mood and affect 2. Tissue integrity |
Sen-so-perceptual alterations (specify) visual auditory, kin esthetic, gustatory, tactile, olfactory. Tissue, impaired integrity |
High risk of deterioration of integrity as evidenced by cognitive impairment manifesting through problems with decision-making, concentration, learning and patients’ memory |
| Rest and Comfort
1. Pain 2. Stress and Coping 3. Fatigue |
Coping: ineffective
Anxiety
|
Risk of pain as evidenced by the release of a lot of chemicals by the patients’ immune system to their blood resulting to widespread inflammation and organ damage
|
| Spiritual Integrity
1. Grief and loss 2. Cultural |
Spiritual suffering Hopelessness Impotence Bereavement dysfunctional Early Mourning |
Risk of hopelessness as evidenced by grief arising from associated pain |
| Affiliation
1. Love and Belonging 2. Social Support Systems 3. Self-Actualization |
Verbal, disorder Social, impaired interaction Social isolation Coping: ineffective Recreation, deficitRole, impaired performance |
Risk of impaired interactions as evidenced by cognitive impairment manifesting through problems with concentration, and patients’ memory |
| Sexual Integrity
1. Reproductive Health 2. Sexual Relationships 3. Sexuality |
Sexual dysfunction Sexuality, altered patterns of |
|
| Safety
1. Infection and Inflammation 2. Immunity 3. Substance abuse 4. Abusive environments |
Infection, high risk of Dysreflexia Injury, high risk Poisoning, high risk of Trauma, high risk of Protection, impaired engaged Violence, high risk: self-injury, injury to other Self-mutilation, high risk of Post-traumatic response Rape, traumatic syndrome of Violation, trauma syndrome: compound reaction Violation, trauma syndrome: silent reaction |
High risk of Dysreflexia as evidenced by bed sores and urinary tract infections |
| Self-Esteem
1. Developmental milestones across the lifespan 2. Health promotion/health beliefs 3. Behaviors 4. Teaching and learning |
Growth and development, altered
Coping familiar development potential Coping:ineffective Health, generating conducts (specify) Treatment, tracking no (specify) Therapeutic regimen, ineffective management of (individual) |
Risk of knowledge deficit on sepsis as evidenced by the presence of learning blocks and misconceptions
|
Section VIII
Medications
(5 Points)
Medication Sheet
| Medication Dose
Brand/ Generic Name |
Mechanism of Action/Indication for Use | Contraindication | Adverse Effects/Side Effects | Nursing Implications
|
Outcomes | Safe Dose
(yes or no) Why is your client on the drug? |
|
Normal saline bolus
|
Intravenous administration through sterile equipment injection | Edema, heart failure | Seizures, renal failure, visual impairment, sodium retention, increase in intracranial pressure, weakness, nausea, sinusitis , rash and ocular irritation | May worsen the prevailing hypotension thus resulting to collapsing of cardiovascular. As such, there is need to monitor the any possible and noticeable signs arising from the fluid volume deficit like dizziness and confusion. Administration of the Normal Saline Intravenous fluids has the potential of causing cerebral edema, and thus should never the administered to patients at high risk of increased intracranial pressure | Increases the patients’ blood pressure through increasing the functionality of the organs(Chang & Holcomb, 2016).
|
To help in raising his blood pressure and increase the his kidneys’ functionality |
| I grams
Vancomycin intravenous
|
Intravenous administration through sterile equipment injection | Hypersensitivity, systemic mastocytosis, hearing loss, kidney disease with potential of resulting to kidney function reduction, neutropils | Fullness in the ears, dizziness, general weakness and tiredness, blood or urine or stool, continuous buzzing and other unexplained ear noises as well as fever without chills | When administering vancomycin, there is need to monitor any relative signs of anaphylaxis or hypersensitivity reactions, skins reactions such as rash and urticaria. One should also monitor any pulmonary symptoms like wheezing, throat tightness, and cough dyspnea and chest tightness (Patel et al., 2020).
|
Treat blood infections, through killing the bacteria and preventing their continuous growth. | To help him in treating the suspected blood infection, which other medications may be ineffective. |
Section IX
Nursing Interventions
(Points 20)
CARE PLAN FOR “ 4 ” (MINIMUM) NURSING DIAGNOSES
| Assessment
Findings |
Nursing Diagnoses
(Actual & Potential Deficits, Wellness Diagnoses) |
Outcomes
Short and Long Term |
Interventions/Nursing Systems
(Dependent & Independent) |
Rationale
(Why are you performing that intervention?) |
Evaluation/Outcome
(What was the actual result?) |
| Subjective:
Patient is experiencing fever, malaise and fatigue.
Objective: high heart rate, blood infection
Vital Signs Blood pressure (113.80 mm Hg), Temperature (101 ºF), Heart rate (110 bpm) , Respiratory rate (18) and Pulse rate ( ox 95%) |
Risk for Impaired Gas Exchange
Risk for infection
Hyperthermia
Deficient Knowledge |
Mr. Daniel will demonstrate respiratory rate and ABGs within the standard parameters, with clear breathing and clear or improved chest x-rays.
No cyanosis or dyspnea is encountered by the client.
Timely recovery would be accomplished by the client; become safe from erythema, drainage, or purulent secretions; and be afebrile. Clinical Care Plan Essay Assignment Paper
No related complications will be encountered by the client. The patient will display temperature within the range of normal and have no chills.
The patient will express the knowledge of the disease process, prognosis and prospective impacts. Knowledge of therapeutic requirements will be expressed by the patient. The patient will get involved in the treatment regimen. The patient will implement the required changes in lifestyle. The patient will execute the required procedures properly and describe the reason for the procedures. |
Track the respiratory rate and depth. Observe the use of accessory muscle or the breathing task.
Auscultate the sounds of the breath. Observe for wheezes, stridor, and ventilation areas that are reduced or absent.
Evaluate the likely cause of infection (for example open wounds or cellulitis, acute abdominal pain, invasive catheter presence, burns, or burning urination).
Examine pain complaints that are out of proportion to the visible indications.
Track the temperature of the patient and pattern. Observe shaking chills or excessive sweating.
Monitor the temperature of the environment. Restrict or use bed linens, when necessary.
Analyze the disease process and expectations for the future.
Discuss the specific risk factors, transmission mode, and infection entry site. |
Due to hypoxemia, circulating endotoxins, and stress, shallow respiration occurs. The inadequate compensatory mechanisms dyspnea and hypoventilation are indicators that ventilatory assistance is required.
Respiratory discomfort and the occurrence of unexpected sounds indicate pulmonary congestion, atelectasis, and atelectasis.
Respiratory tract infections and UTIs are the most frequent causes of sepsis; next include soft tissue and abdominal infections. The usage of intravascular equipment is another source of hospital-acquired sepsis.
Because of group A beta-hemolytic streptococci (GABHS), pain that is much like pressure over a cellulitis area can signal the formation of necrotizing fasciitis, requiring immediate action.
The temperature of 102 ° F to 106 ° F suggests the process of acute infectious illness. The pattern of fever can assist in the diagnosis.
To retain a close-to-normal body temperature, room temperature and linen should be adjusted.
Explaining the illness and clinical objectives offers a background knowledge from which patient can make knowledgeable decisions.
Knowledge of means of transmitting infections offers an impetus for prevention strategies to be designed and instituted. |
There patient achieved respiratory rate and ABGs within the normal range with clear breathing. Additionally, the patient did not experience cyanosis or dyspnea.
Mr. Daniels healed in a timely manner and became free from erythema, drainage, or purulent secretions.
The body temperature of Mr. Daniels was displayed as within normal range.
Mr. Daniels displayed an in-depth understanding of the disease process, and demonstrated an understanding of therapeutic needs. He was more willing to take part in the treatment regimen, and mentioned he understands the importance of making necessary lifestyle changes. |
References
Bhan, C., Dipankar, P., Chakraborty, P., & Sarangi, P. P. (2016). Role of cellular events in the pathophysiology of sepsis. Inflammation Research, 65(11), 853-868.
Chang, R., & Holcomb, J. B. (2016). Choice of fluid therapy in the initial management of sepsis, severe sepsis, and septic shock. Shock (Augusta, Ga.), 46(1), 17.
Patel, S., Preuss, C. V., & Bernice, F. (2020). Vancomycin. StatPearls [Internet].
Clinical Care Plan Essay Assignment Paper