ICU Care plan help please =]

[NewNurse91D]

Hi guys!!

So I'm in 3rd semester and just did my ICU rotation; thus my ICU specialty paper & care plan is due in a week. I am working on it and just want a little 'guidance' or just someone to bounce ideas/concepts around. ALSO because I kinda want to understand my pt's condition better too.

SOO:

73yo F.

Has been in the ICU for over a week now.

She came into the ED w/ dx of status epilepticus, confusion and dementia.

HX: 2 CVAs (one 10 yrs ago and other ~ 4 yrs ago), HTN, DM t2, CHF.

Her husband has been taken care of her (she's total care, nonverbal, immobile and bedbound) for 10+ yrs @ home.

She's on a ventilator: mode is AC, PEEP of 5cm, FiO2 28%, Tidal volume 300 and rate is 8min. Nurse said that "those are weanable values/settings BUT when they attempted to wean her a few days ago, she went into SVT. Thus, they had to put her bck on the vent & neurology came up & eval her and said that she has "Onidine's Syndrome" and its unlikely that she will be able to come off resp. support.

She does have an OG tube for nutrition too.

And also has VAP & MERSA.

Her ABGs:

pH: 7.528

pO2:101.6

pCO2: 38.9

HCO3: 31.7

BE: 8.3

O2 sat: 98.6%

Labs:

There's QUITE a lot of labs so I'm going to list the abnorm. ones and let me know if you want the others:

WBC: 12.8

RBC: 3.42

Hgb: 9.2

Blood glucose: 169

Hct: 31.4%

CO2: 34

BUN/Creat ratio: 25

lactic: 2.2

Tot. Protein: 8.2

A/G Ratio: 0.9

CBC w/ diff:

EOS: 0.45

GRAN: 7.93

Imm GRAN: 0.07

NOW my assessment:

Neurological: Pt. wasNonverbal.Level of Consciousness: Sedated. Pupils reactive to light bilaterally, movement is sluggish. Unable to assess further r/t sedation and condition.

Psychological: RASS Score= -3 moderate sedation. Eye opening/movement to voice w/out eye contact.Unable to assess further r/t condition and sedation.

Cardiovascular: Peripheral pulses present and steady bilaterally in all extremities. Good capillary refill in all extremities. Apical HR-84bpm, rhythm is regular without murmurs or irregular beats.S1 & S2 audible.1+ non-pitting edema noted in RUE and LUE. Rhythm: Normal Sinus Rhythm

GU: Foley catheter. Foley patent, collection bag has 300mL of clear, light-yellow urine.

Output during shift: 500mL

GI: Bowel sound active x4 Quadrants. No distension or apparent tenderness upon palpitation.OG tube in place and patent. Continuous TPN is running @ 30mL/hr.

Integumentary: Warm, Diaphoretic. L arm-multiple surface abrasions (may be r/t the LUE edema). Mepilex Sacral pad-prophalytic precautions- clean, dry and intact. Double lumen subclavian central line on R side of chest

Respiratory: Intubated with 7mm ET tube, 23cm at the lip. R & LUL clear and diminished. RLL=clear & diminished. LLL=crackles.

Musculoskeletal: No movement in all extremities.

SO…I really don't even know what to do with the information.

WHAT I DID DURING MY SHIFT: suctioned her et/vent, checked placement of OG Tube and admin a water bolus, admin insulin and checked BG, turned on the percussions on her rotation/proning sport bed, sedation, PO care and PO suctioning.

I would really appreciate some questions or anything to jog some thinking. Im drawing a blank honestly.

Thank you.

[Shagce1]

You have a bunch of information. Do you not have any ideas? A starting point? Even a complete stab in the dark? What about her airway or skin? I just quickly scanned your information and maybe you could go somewhere with that. I personally don't like doing my own care plans, so won't put a ton of thought into yours without a little background of what you might think. I am guessing others might want you to try first before helping too much.

[NewNurse91D]

Yes very true.

And my thought process:

She has impaired ventilation/respiratory function and neourology thinks that she is unweanable. SO their talking about a more perminant repiratory device like a trach.

She has impaired skin integrity and is at a huge r/f decubs.

she's non verbal and immobile.

She needs TPN.

She has pneumonia and MERSA

She has a hx of CVA's and has HTN so there some circulatory issues (also not to mention her edema)

SO what do I do as a nurse?

Antibiotics, sedations, family education r/t the long-term need to resp. support, fluids and nutrition. Preventing any resp. complications (so turn & percussions, PO care), ptrevent bed sores, and prevent and DVT's or PE's-so ASA, lovenox. Seizuree precautions. Aspiration precautions-suctioning and PO suctioning.

Whats my priority?

...hmmm.

I would say the VAP & MERSA treatment anddddd skin/fluid/dvt/aspiration precutions/prevention?

That's where I kind of get stuck.

[NewNurse91D]

I ALSO think that a big thing is making sure the care giver (the husband, who has been her primary care giver for 10+yrs) is informed and has resources.

Making sure that he is educated on her condition and what neurology said r/t ventilator weaning issues.

[Shagce1]

Yes. I was totally thinking about the husband and his needs. Wasn't sure if your care plan could involve him or not. Education and support will be biggies.

[icuRNmaggie, BSN, RN]

I think that this lady has no quality of life and she belongs on hospice to allow her natural death. The code status must be addressed and a Palliative care consult should be ordered. All of this should be discussed in the team meeting. If the spouse

refuses their services the case should be referred to

the Ethics Committee.

[NewNurse91D]

good point!! thank you

[NewNurse91D]

yeah! I am definitely going to incorporate that

[icuRNmaggie, BSN, RN]

The definition of futile medical care is that the patient receives no benefit other than the prolongation of life.

Sadly she will probably receive a trach and PEG, remain ventilator dependent, and be d/c'd to an LTACH.

[NewNurse91D]

AND I am SO confused with her abg results. I've been trying to look up info on the internet but can't find anything useful. Any suggestions?

[NewNurse91D]

HOWEVER, I did just find that high lactic acid levels can indicate tissue hypo perfusion. And my patient had high lactic Acid levels. That's interesting right?

[NewNurse91D]

But she doesn't have any other indicators of tissue hypo perfusion. Her cap refill was good, good peripheral pulses, etc