CAREPLAN ISBAR

7/30/2019 CAREPLAN ISBAR

1/3

Name: Amanda Simpson Date: March 8/9, 2013

Situation Background

Assessment

Name: R.P Age: 66 years old

DOB: 10-17-1946 Room #

Gender: MALE FEMALE CODE STATUS: FULL DNR

Admit date: 3/8/2013 at 0145 Allergy: PenicillinAdmit DX: Acute Respiratory Failure and

Pneumonia

Past Medical Hx: Double lung transplant in 2004

due to his COPD, Coronary Artery Disease, Stent

placed in 2003, Ankle Fracture, Single Vessel

disease, Hx of atrial fibrillation, diabetes mellitus

diagnosed in 2008, large squamous cell tumor

resection of his chest with skin graft placed, HTN,

chronic kidney disease, history of rejection and

chronic host versus graft, chronic kidney disease

Surgical Procedures: On Tuesday March 6, 2013

patient had large squamous cell carcinoma tumor

of chest wall resection and skin graft was placed

Current VS: VS Q Continuous

BP: 159/122

Pulse: 130bpm

Resp: 22RR controlled by Vent

Temp: 36 degrees Celsius

Sao2: 100%

DRIPS:

1. NS 0.9% 1000mL @ 40mL/hr.

2.D5W 100mL+Midazolam 50mg

@ 6mL/hr. for SEDATION

3.D5W Baxter (DEPH)

100mL+Fentanyl Citrate

1000mcg @ 10mL/hr. for PAIN

4.Heparin 12u/kg=1000u/hr. =

30mL hr.

LUNGS: Diminished breath

sounds bilaterally at the bases.

No wheezing or crackles

Neurovascular:

PPP, edema +1 pitting, LE cool

and dry, LE color blue-purple,

capillary refill < 4 seconds, pt.

has general edema and appears

puffy, skin turgor brisk, UE warm

and dry, UE capillary refill < 3

seconds.

Neuro: Patient under sedation

due to being on ventilator. The

patient was briefly brought out

of sedation and the patient

responds to commands but

severely agitated, sedation was

restarted. Pt. unable to

communicate and while awake

was able to move all extremities.

PERRLA 3mm.

Respiratory:

NC/NRB/Bi-Pap/Vent

Breathing TX: PRN Q6H

Albuterol Sulfate 0.5mL

nebulized

Vent Setting: CMV

FiO2: 50

TV: 550

Rate: 22

Peep: 7

Patient is not breathing aboveVentilator

Cardiac:

rhythm : patient was in NSR then

converted to A-Fib with RVR

GI:

Abdomen: soft, symmetrical, no

distension noted.

Elimination: I & O Q 1H

Foley: placed 3/8/13

Last BM: UNKNKOWN


2/3


Recommendations

Special treatments/Needs: Previous Nurse had stated that the patient was stable and that there were

plans to have the patient flown to an out of state hospital, where he received his lung transplant.

Everything was prepared for the patients transport.

Abnormal Labs: Albumin 2.9 Low: Arterial Bicarb 17.8 Low: PCO 31 Low: pH 7.29 Low: pO2 87.3 High:

BUN 54 high: Calcium 7.9 Low: CO2 18 Low: CPK: 315 High: Creatinine 2.80 High: HGB 8.2 Low: HCT 25.7

Low: PT 15.8 High: PTT 93.4 High: INR 1.27 High: Ionized Calcium 5.14: Lactic Acid 5.5: BNP: 2547.5: WBC

15.33 high:Medications:

Docusate Sodium 100mg BID Heparin 5000 units in 1 mL Injection Sub cut Q8H for DVT prophylaxis Solu-Cortef 100mg IV Q8H Apidra 2-7 units sub cut three times daily and at bedtime Meropenem 500mg = 100mL IV Q12H Metoprolol tartrate 50mg tablet via NG tube BID

Monitor: Continuous

DAILY WEIGHT: 102.4kg

NG/OG/feeding tube: NG tube,

right nare @ 58cm. receiving

Nepro at 40mL/hr.

Bowel sounds: hypoactive in all

quadrants.

Flatus: None noted while at

clinical

Incontinent: Bowel/Bladder

Muscle/Skeletal:Patient when awake was able to

move all extremities on

command, no spontaneous

movement while sedated

TX:

PT/OT/ST- None scheduled at

this time

Skin:W/D/I: Upper extremities

Diaphoretic: No

Cold/Clammy: Lower extremities

cold and dry

Dressings: Mid upper chest C/D/I

Abdominal dressing C/D/I

At risk for Ulcers: YES- patient

on air mattress

Braden Score: 14

Activity: Complete bed restTurn: Turn Q2H

Falls Risk: YES

Score: 14

Pain:

Scale: Wong-Baker Faces

Location: N/A

Rating: 0

Last Pain Meds: Patient on

continuous Fentanyl drip at

10mL/hr.

IV: Right antecubital 20 gauge-

patent. Central Line Site: Right

Int Jugular Quad lumen

Nutrition: NPO feeding via NG

tube Nepro at 40mL/hr.

Precautions: Patient is not in

isolation

Psychosocial:

Married; lives with wife. Wife at

Bedside

Devices: SCDS, continuous

cardiac monitoring at bedside

Diabetes:

BS Checks Q6H

Family: Wife at bedside Skin Care/Wound Care:

Bed bath completed Q8H or

PRN, dressings C/D/I, instructed

not to remove or changedressings. Routine checks were

done to check overall skin

integrity

Drains: No Drains


3/3


Micafungin 100mg=100ml IV Q24H Mycophenolate Mofetil HCL 500mg=250mL IV Q12H Pantoprazole IV 40mg=101mL Q24H protocol Tacrolimus 0.5mg capsule via NG tube Q12H Warfarin 2mg tablet via NG tube every evening

List Significant Data: Patient converted to NSR in the 70-80bpm range to atrial fibrillation with RVR, thephysician was called and the patient was started on an IV drip of Heparin 12u/kg= 100units per hour =

30mL/hour. The client currently has bilateral soft wrist restraints. Plan is to send the patient out of state;

we are awaiting a bed at the receiving hospital. The patient is immunosuppressed and is currently

septic. The patient is fluid volume overloaded. The patients lab data has improved since his admission

early yesterday morning. An attempt was made during the day to wean the patient of the ventilator but

was unsuccessful as the patient could not maintain oxygen saturation greater than 92%. My

interpretation of the ABGs indicating partially compensated metabolic acidosis.

Lab/Diagnostics: Chest X-ray on 3/8/13 indicated cardiomegaly with evidence of fluid overload and

small bilateral pleural effusions. Right mid lung edema or superimposed infection

Vital Sign Ranges for last 24 hours:

BP: 123/67- 159/22

HR: 69-150bpm

RR: 22 VENT SET

Temp: 36-36.4 degrees

CO/CI/PAP/PAWP: Not Applicable

Pulse Ox: 100%

Pain Scale: 0- Wong Baker faces Scale Pt. has

fentanyl drip to control pain

24 hour I&O: Input: 2603mL Output: 1020mL

Net: 1583mL

24 Drain Output: Not Applicable

Diet %: Breakfast: NPO Lunch: NPO Dinner:

NPO

BS Ranges: 181-213

Admit Weight: 100Kg

Current Wt.: 102.4K

TPN Intake: 480mL last 12hours

Residuals: __10-20mL

Recommendations for the next nurse: The patient is currently on a Heparin drip that had to be started

in the middle of the night because he converted to atrial fibrillation with RVR, the patient has not

converted back to NSR as of yet; The protocol is in the chart. We are still waiting for the patient to be

life-flighted to an out of state hospital and everything is ready in the chart. We have been watching his

rhythm closely since the conversion and suggest you do the same. Labs have been ordered for this

morning at 0800 including CBC, CMP, Mag, Phos, ABGs and a PTT. The patient should also have the

results from this mornings CXR soon. Other than the conversion the night went smoothly, the physician

stated he would be back this morning to evaluate how the Heparin is working. The patient has an IJ

central line with quad lumens; all of the lines are patent.

Documents

CAREPLAN ISBAR