Care Plan

Student: Rebecca Ramirez Date: 3/7/2020

Course: NSG-430 CC Instructor: Professor Sheila Arnberger

Clincial Site: Banner Del E. Webb Medical Center Client Identifier: J.D. Age: 37

Reason for Admission: Presented to BDWMC for altered mental status, alcohol withdraw, developed acute hypoxic respiratory failure,
aspiration pneumonia, and delirium tremens. He required ventilatory support and was extubated 2/27/2020.

Medical Diagnoses: Alcohol withdrawal syndrome Clinical Manifestation(s):

Pathophysiology: Clinical Manifestations J.D. presented with:
Alcohol withdrawal syndrome results from an in balance in the brain of - Delirium tremens
inhibitory and excitatory neurotransmitters. When taken in large amounts, - Hallucinations
alcohol has an anesthetic and depressive property. Abrupt withdrawal of - Diaphoresis
chronic alcohol consumption results in brain hyper-excitability due to the - Anxiety
neurotransmitters, glutamate and GABA, previously inhibited by alcohol - Tachycardia
are no longer inhibited. - Nausea
Risk factors: Other common clinical manifestations:

Risk factors included for the development of alcohol withdrawal - Agitation

syndrome are people who have addiction to alcohol or those who consume - Insomnia
large amounts of alcohol on a daily basis. - Hyperactivity
- Seizures
(Lewis, Bucher, Heitkemper, Harding, Kwong, & Roberts, 2017) - disorientation

Assessment Data

Subjective Data: Patient is anxious and continues to hallucinate along with having a hard time forming complete sentences. Complained of
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wanting to lay back down when moved to the bed side chair.
VS: Labs: Diagnostics:
(time: 08:02) o WBC: 14.1 (4-11) - Chest single view adult portable (03/07/2020) –
- High white blood cells can be due to pulmonary hypoinflation  no evidence of
T : 36.8
the possible sepsis that is being tested pneumonia
BP: 142/94 for - Chest single view adult portable (02/26/2020) –
o RBC: 4.08 (4.3-5.7) slight increase in basilar opacities, atelectasis
HR: 124
- Low red blood cells due to alcohol’s versus pneumonia, compared to prior  ETT
RR: 23 effect on hematopoiesis remains in place without pneumothorax
O2 Sat: 94 o Hgb/Hct: 11.9 (13-17, 36.2 (39-50)
- Low H&H can be due to the low red
Pain: 8
blood cells attributed to extreme
(time: 16:36) alcohol consumption and iron
deficiency
T : 36.1
o AST: 63  (10-30)
BP: 133/82 - Liver enzymes high due to his history
HR: 123 of alcohol abuse
o ALT: 152  (10-40)
RR: 25 - Liver enzymes high due to his history
O2 Sat: 93 of alcohol abuse

Pain: 7

(Lewis, Bucher, Heitkemper, Harding, Kwong,

& Roberts, 2017)
Assessment: Orders:

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Past medical history- - CT (03/06/2020)  negative for pulmonary embolism
- Follow up SLP (03/06/2020)
- Asthma
- Precautions- Swallowing (speech) (03/06/2020)
- Tobacco use
- Coccidioides screen with reflex to CF Titer when indicated
- Alcohol abuse
(03/07/2020)
- Chronic back pain
- Potassium, phosphorus, magnesium serum (03/07/2020) 
Neuro- labs pending
- Delirium/Sedation assessment (03/07/2020)
- Alert, Oriented x 1
- Eyes-open spontaneously, no visual problems
- Pupils- Equal, round, and reactive
- Pupil size: 3mm in both right and left eyes
- Speech-dysphagia
- Affect- alert, cooperative, moderate memory impairment
- MSAA score: 8
Respiratory-
- Respiratory effort- accessory respiratory muscles with labored
respirations
- Oxygen status- NC 3L humidified
- Cough- loose
- Sputum- moderate, copious oral secretions
- Left lower lobe breath sounds: diminished
- Left upper lobe breath sounds: coarse crackles
- Right lower lobe breath sounds: diminished
- Right upper lobe breath sounds: coarse crackles
Cardiovascular/Vascular-
- Edema- none
- Nail bed color: pink
- Heart rhythm: regular

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 - Cardiac rhythm: sinus tachycardia
- Capillary refill- brisk, < 2 seconds
- Pulse- dorsalis L/R: palpable at 2+, not easily obliterated
- Pulse- radial L/R: papable at 2+, not easily obliterated
GI-
- Abdomen- distended, non-tender
- GI symptoms: nausea
- Bowel Sounds- present in all quadrants
- Stool output: 1x
- Morbid obesity
GU-
- Urinary elimination: indwelling catheter
- Urine- clear, yellow
- Frequency- every hour
Skin-
- Color- appropriate to ethnicity
- Status- intact, diaphopretic, warm
Diet-
- NGT
- Continuous feeding
- Formula: vital high protein at 65 ml/hr
IV Access-
- 20g in Left forearm
- 20g in Right forearm
Medications

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ALLERGIES: NKDA

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Olanzapine 2.5mg PO daily Decreased manifestations Neuroleptic malignant Inform patient of
of psychosis. syndrome, seizures, possibility of
(Vallerand, Deglin, dizziness, headache, extrapyramidal
Sanoski, 2017). restlessness, sedation, symptoms and
weakness, amblyopia, tardive dyskinesia.
rhinitis, orthostatic Advise patient to
hypotension, constipation, change positions
dry mouth, increased liver slowly to minimize
enzymes, orthostatic
hypotension.
Medication may
(Vallerand, Deglin, cause drowsiness.
Sanoski, 2017).

(Vallerand, Deglin,
Sanoski, 2017).

100mg PO BID Helping with  Cramps/ diarrhea Assess for

docusate (Colace) constipation. Works by Rashes abdominal
promoting water (Vallerand, Deglin, distension, Bowel
incorporation into stool Sanoski, 2017). sounds, assess stool
which results in softer including: color,
fecal mass consistency, and
(Vallerand, Deglin, amount
Sanoski, 2017). (Vallerand, Deglin,
Sanoski, 2017)

1mg PO daily Prevention and treatment Derm: rash Assess patient for
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Folic Acid of megaloblastic and CNS: irritability, signs of
macrocytic anemias. difficulty sleeping, megaloblastic
Restoration and malaise, confusion anemia (fatigue,
maintenance of normal Misc: fever weakness, dyspnea)
hematopoiesis. (Vallerand, Deglin, before and
(Vallerand, Deglin, Sanoski, 2017). periodically
Sanoski, 2017). throughout therapy.
Monitor plasma
folic acid levels,
hemoglobin,
hematocrit, and
reticulocyte count
before and
periodically during
therapy.
(Vallerand,
Deglin, Sanoski,
2017).

40 units SC HS Used to treat edema due Tinnitus, toxic epidermal Assess fluid status
Furosemide to heart failure, hepatic necrolysis, metabolic by monitoring daily
impairment of renal alkalosis, hypovolemia, weight. Monitor BP
disease, Hypertension. pancreatitis and and pulse prior and
Works by inhibiting the parasthesisa one hour after
reabsorption of sodium (Vallerand, Deglin, administration.
and chloride from the Sanoski, 2017). (Vallerand, Deglin,
loop of henle and distal Sanoski, 2017).
renal tubule.
(Vallerand, Deglin,
Sanoski, 2017).

16 mg PO Q6H PRN Prevention of nausea Serotonin Syndrome, Assess for nausea,

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(ondansetron) Zofran vomiting by blocking the
effects of serotonin
receptor sites in the vagus
nerve. (Vallerand, Deglin,
Sanoski, 2017).
14mg Transderma Once daily Adjunct therapy in the
Nicotine l management of nicotine
withdrawal in patients
desiring to give up
cigarette smoking.
Provides a source of
nicotine during controlled
withdrawal from
headache, dizziness, vomiting,
drowsiness, fatigue. abdominal
Torsade de pointes. distention and
Constipation, diarrhea, bowel signs before
abdominal pain, dry administration.
mouth, increase liver Monitor for signs
enzymes. Steven-Johnson and symptoms of
Syndrome. (Vallerand, serotonin syndrome
Deglin, Sanoski, 2017). (mental status
changes, autonomic
instability,
neuromuscular
symptoms,
seizures, GI
symptoms). Assess
for extrapyramidal
effects. May cause
a transient increase
in serum bilirubin,
AST and ALT
levels. (Vallerand,
Deglin, Sanoski,
2017).
HA, Insomnia, Assess smoking
tachycardia, HTN, history. Assess for
Increased appetite, withdrawal
Burning at patch site, symptoms.
erythema, pruritus, Evaluate progress
hypersensitivity in smoking
(Vallerand, Deglin, cessation
Sanoski, 2017). periodically.
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 smoking. Lessen sequelae Assess for
of nicotine withdrawal toxicity/overdose
(Vallerand, Deglin, which would
Sanoski, 2017). include N/V,
Diarrhea, increased
salivation,
abdominal pain,
HA, dizziness,
auditory and visual
disturbances,
weakness, dyspnea,
hypotension, and
irregular pulse
(Vallerand, Deglin,
Sanoski, 2017).
40mg SC BID Prophylaxis of blood clots Fever, Nausea, Monitor blood
Lovenox in patient who is staying Hemorrhage from any studies (Hct, CBC,
in hospital and not as site, and coagulation studies,
active as they would be thrombocytopenia etc.), assess patient
otherwise. (Vallerand, Deglin, for bleeding gums,
(Vallerand, Deglin, Sanoski, 2017). petechiae, or
Sanoski, 2017). ecchymosis
(Vallerand, Deglin,
Sanoski, 2017).
17mg PO daily Treatment of occasional Urticaria, abdominal Assess patient for
Miralax [Polyethylene constipation. Works by bloating, cramping, abdominal
glycol] drawing water into the flatulence, nausea distention, presence
lumen of the GI tract. (Vallerand, Deglin, of bowel sounds,
Vallerand, Deglin, Sanoski, 2017). and usual pattern of
Sanoski, 2017). bowel function.
Assess color,
consistency, and
amount of stool

8
 produced.
(Vallerand, Deglin,
Sanoski, 2017
0.5 mg IV PRN Anxiety disorder, Slurred speech, ataxia, Assess patient for
Lorazepam (ativan) Insomnia, panic disorder hangover, respiratory CNS effects
(Vallerand, Deglin, depression, weight gain, because these
Sanoski, 2017). physical and effects are more
psychological dependence sensitive to these
(Vallerand, Deglin, effects. Assess risk
Sanoski, 2017 for falls (Vallerand,
Deglin, Sanoski,
2017

10mg PO Q6H PRN Moderate to severe pain. Confusion, sedation, Advise patient to
Oxycodone Binds to opiate receptors dizziness, dysphoria, call for help when
in the CNS and causes euphoria, constipation, ambulating due to
CNS depressant by floating feeling, the drug causing
altering response to hallucination, HA, dizziness and
painful stimuli unusual dreams, dry drowsiness 
(Vallerand, Deglin, mouth, N/V, flushing, Assess the type,
Sanoski, 2017). sweating location, and
(Vallerand, Deglin, intensity of pain
Sanoski, 2017). prior and the peak
after administering.
Assess BP, RR, and
pulse before and
after
administration, If
RR is below 10,
assess the level of
sedation.
(Vallerand, Deglin,
Sanoski, 2017).

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time-specific, Nursing or interprofessional Provide reason why Was goal met? Revise
reasonable, and attainable. interventions. intervention is the plan of care
indicated/therapeutic. according the client’s
Provide references. response to current plan
of care.
Priority Nursing Diagnosis
Ineffective breathing pattern related to effects of sedative drugs to decrease alcohol withdrawal symptoms as evidence by the usage of accessory
respiratory muscles and a respiratory rate of 23
The rationale in picking this NANDA as a priority nursing diagnosis is because the patient’s breathing will take priority above other care
measures taken during his stay in the ICU.

J.D. will be free of J.D. will have a 1. Monitor rate, depth 1. To identify the type 1. The goal was
ineffective breathing by respiratory rate of 12-20 of respirations and of breathing pattern met during my
discharge by end of shift type of breathing and assess any shift. We were
patter better or worsening able to
J.D. will have no use of 2. Ensure proper body usage of accessory successful
accessory muscles and alignment for muscles monitor the
will demonstrate quiet
optimal breathing 2. To allow for good patient’s
respiration by end of shift
pattern lung excursion and respiratory effort
3. Review J.D’s chest chest expansion and usage of
x-rays, ABG’s, and 3. To monitor for accessory
pulse ox presence of muscles. Patient
secondary had a respiratory
complications such rate of 25 with
as pneumonia and use of accessory
atelectasis muscles at end of
shift. We will
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 continue to
monitor further
changes of
status.
2. The goal was
met to help
patient into a
comfortable
position to allow
effetive
breathing. We
will continue to
ensure this
intervention
throughout his
care
3. The goal of
reviewing
patient’s x-rays
during my shift
was met. Patient
had a chest x-ray
done during my
shift revealing
no signs of
pneumonia.
(Phelps, L.L., Ralph, S.
(Phelps, L.L., Ralph, S. S., S., Taylor, C.M, 2017) (Phelps, L.L., Ralph, S.
Taylor, C.M, 2017) S., Taylor, C.M, 2017)
Secondary Nursing Diagnosis:
Anxiety related to physiological withdrawal as evidence by increased hopelessness and tension.
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J.D. will be free of J.D. will verbalize a
anxiety by discharge reduction of anxiety to an
acceptable or manageable
level by discharge
J.D. will demonstrate two
problem-solving skills and 2. Orient the patient
name two outside
resources for professional 3. Administer
help
1. Determine the 1. To effectively cope 1. The goal of
cause of anxiety and treat the main determining the
and reassess level trigger of anxiety cause of anxiety
of anxiety to better the health was not met.
throughout stay in of the patient’s Patient was too
the ICU condition both disoriented and
psychologically unable to form
to reality and physiologically complete sentences
2. To prevent further to do so. We will
medications as anxiety after continue with this
indicated experiencing intervention to
hallucinations better the patient’s
3. Anti-anxiety health.
medications are 2. The goal of
given during with orienting the
drawl to help client patient to reality
relax and be less was met
hyperactive throughout the
entire shift. There
were many
moments
throughout the day
where the patient
needed to be re-
oriented back to
reality after
experiencing a
hallucination
3. The goal of
administering
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 medications as
indicated was met
throughout the
shift. Ativan was
given to minimize
his anxiety
symptoms.

Phelps, L.L., Ralph, S. S.,

Taylor, C.M. (2017)
Phelps, L.L., Ralph, S. S., Phelps, L.L., Ralph, S. S.,
Taylor, C.M. (2017) Taylor, C.M. (2017)

Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

REFERENCES:

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Lewis, S. L, Bucher, L., Heitkemper, M. M., Harding, M. M, Kwong, J., & Roberts, D. (2017). Medical-surgical nursing: Assessment

and management of clinical problems (10th ed.). 

Phelps, L.L., Ralph, S. S., Taylor, C.M. (2017). Spark & Taylor’s nursing diagnosis reference manual (10th ed). Philadelphia, PA:

Wolters Kluwer

Vallerand, A.H, Deglin, J.J, Sanoski, C. A., (2017). Davis’s drug guide for nurses (15th ed) Philidelphia, PA: F.A. Davis Company

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