1) The patient is a 65-year-old Jamaican female admitted with acute on chronic congestive heart failure and a history of liver disease and cardiac issues including atrial fibrillation. 2) She presented with a nosebleed and was intubated for declining mental status and risk of aspiration. Lab work showed elevated ammonia levels and she is being treated with lactulose and rifaximin. 3) The care plan addresses monitoring her bleeding risk from coumadin use, managing her cardiac and liver conditions, and ensuring her nutrition and comfort during her ICU stay.

1. CARE PLAN SEPSIS and other medical conditions
Unformatted Preview Concept Map Student Name: Instructor: Erickson’s Developmental
Stage Related to pt.& Cite References (1) History of Present Illness (HPI), Pathophysiology
of Admitting Dx (Cite References) Medical, Surgical, Social History (1). Patient Education (In
Pt.) & Discharge Planning (home needs) In patient: Acute on chronic systolic and diastolic
Congestive Heart Failure (CHF). Home care: Cultural considerations, ethnicity, occupation,
religion, family support, insurance. (1) (14) Socioeconomic/Cultural/Spiritual Orientation &
Psychosocial Considerations/Concerns, to include the following Social Determinants of
Health Diagnostic Test/ Lab Results with dates and Normal Ranges (3) Test Norms BUN 7-
20 mg/dL CREATIN INE 0.5 to 1.1 mg/dL PT 11-12.5 seconds INR 0.761.27 WBC 4.511.0
Hct 37-47% Hbg 12-16 g/100m L PLATELE TS Na K Date 9/15/ 19 9/15/1 9 Current Value
43 1.3 9/15/ 19 9/15/ 19 9/15/1 9 9/15/1 9 9/15/1 9 27.7 H 150 to 400 × 10 9/L 9/15/
19 114 L 135– 145 mEq/L 9/15/1 9 136 3.5-5.0 mEq/L 9/15/1 9 3.0 Patient Information
(1) Name: A.J. Age: 65 Gender: F Code Status: Full Resuscitation DPOA: None Living Will:
None 2.4 H Chief Complaint Surgical History Patient presents to the ER with complaints of
nosebleed Implantable Cardioverter Defibrillator on 06/23/2017 PICC line on 09/11/2019
Admitting Diagnosis Acute on chronic systolic and diastolic CHF Social History 7.60 Medical
Management/ Orders/ Medications & Allergies (2) 28.0 L Name Dose RT Freq . 1mg4ml IV
Pus h Dail y 80mg/ hr IV 9.3 L MOA Lactulose . Bumetanide Rifaximin Protonix Medical
History Ms. A.J. is a 65 year old Jamaican female with an extensive past medical history of
end-stage liver disease with hepatic encephalopathy, CHF, atrial fibrillation, valve
replacement requiring Coumadin, prior cardiac arrest and an Implantable Cardioverter
Defibrillator (ICD) placement who initially presented to FMC ER from nursing home on
09/10/2019 with epistaxis. Patient’s epistaxis was controlled with silver nitrate
cauterization packing in the ED. She was upgraded to ICU to worsening bleed and
subsequently required intubation for airway protection with worsening encephalopathy an
high risk of aspiration on 09/11/2019. She was provided with Fresh Frozen Plasma (FFP)
and bleeding is now controlled. An ammonia was drown, patient is severe lethargy, and
came back elevated at 141. Patient is on Lactulose and Rifaximin. Patient is allergic to
Penicillins and Tape. ` RN Considerations Onset/Peak/ Duration (Insulin) Patient lives in a
nursing home. He has three daughters and two sons. Patient used to smoke and consume
alcohol occasionally. There is no history of drug consumption. Priority nursing diagnosis #1
Vital Signs (4) Neurological (5) Cardiovascular (6) Atrial Fibrillation Respiratory (7)
Priority nursing diagnosis #2 Bleeding related to Coumadin use as evidence by………

2. Temperature: 98.7 F Pulse: 65 Respiratory Rate: 21 BP: 120/56 SpO2: 100 09/15//2019
Patient is confused Currently disoriented X4 Sedated Worsening Encephalopathy
Implantable Cardioverter Defibrillator on 06/23/2017 Coumadin 2mg qd for life saving
purposes Acute ventilatory dependent. Respiratory failure. Patient was intubated for airway
protection on 09/11/2019 Altered cardiac status related to fluid volume overload/ CHF as
evidence by…….. GI (9) GU (10) Rest/ Exercise (11) Epistaxis with concern of GI bleed in the
setting of coagulopathy. Abdomen is nondistended And soft Folic Catheter in place Acute
kidney injury with worsening azotemia Acute GNR cystitis Status: Bed Needs total
assistance ICU monitoring Psychosocial (14) Misc. (Ht/Wt) Nutrition/Hydration (8) ETand
OG tube in place 09/11/2019 Outcome/Goal #1 Patient’s bleeding will be controlled and
vital signs returned to baseline within normal limits. Integumentary (12) Endocrine (13)
Skin is intact Nopressure ulcers PICC line inserted on 09/11/2019 • • • • • • • •
Interventions #1 Observe for change in mental status Observe for changes in skin color,
turgor and temperature Monitor for tachycardia and hypotension Monitor and record blood
loss Monitor CBC, PT, PTT Monitor procedural site for further signs and symptoms of
bleeding. For bleeding apply direct manual pressure to procedural site and notify physician
Report any change of vital signs or procedural site to the physician Blood Aspiration
Admission weight: 190 lb Height: 5’2 Interventions # 2 • Assessment/ Evaluation #2
Assessment/ Evaluation #1. PC Outcomes/Goal Potential Complications/ at risk for
Outcome/Goal #2 Patient will have optimal cardiac functions PC Interventions Administer
medications IV drips as needed • Monitor Electrolytes/EKG’s and Cardiac Enzymes as
ordered • Monitor vital signs/Hemodynamics, rhythm strips and report changes to
physicians • Report malfunctioning pacer and AICD to Physician …….. PC Evaluation Plan
References