Help! Sepsis care plan, patient died, not enough data

[ER(notso)n00b, ASN, RN]

I started my first clinical rotation this week. On Wednesday, my instructor chose a patient for me and told me to look at the chart and get the history, meds, labs, etc. The problem was it was right during shift change and the nurse kept taking the chart so I didn't have enough time to look at everything. Not even close. I have evening clinicals and we had spent the first several hours orientating to the hospital and the patients were chosen at 6:30pm, 1 1/2 hours before our shift ended. I was able to get the admission history, vitals, and lab values from admission, plus about 5 meds. The patient was admitted 2 weeks ago so it was old information. On Thursday I came in and was just about to get report from the nurse so I could go do my assessment when the patient expired. I did a brief physical assessment on the body then did the postmortem care and bagged and tagged the body. The problem is I still have to do a care plan on that patient and I have very little information. My instructor is fair and only expects one nursing diagnosis but I just don't have enough information! I feel like all I can do is a hypothetical care plan since I never got to see the patient while he was alive. I am stuck and have no idea where to even go with this. What do I do?

[Esme12, ASN, BSN, RN]

Care of the Patient with Sepsis

Care of the Critically Ill Patient

Caring for the ICU Patient at the End of Life

http://www.ccmtutorials.com/intro/overview/page_02.htm

Go to these links.......I think it will have what you need.:loveya:

[ER(notso)n00b, ASN, RN]

Thank you so much! I glanced briefly at those links and they are all exactly what I need. I'll let you know how it goes.

[guest042302019, BSN, RN]

Another suggestion if I may. I'm sure you've been told this, but I figure I would say something. Try to avoid using euphemisms (word substitution) for death. I know what you meant by "expired" but if you say that to a patient's family like, "I'm sorry. John has passed." Passed what? Gas? You see what I mean? It's almost second nature in conversation to use word substitution for death in our society. No one likes to talk about it. But, there's no clearer words than, "death, dead, or died." Take care.

[nurseprnRN, BSN, RN]

"gone? whaddaya mean, he's gone? gone where?" floridatrail has it exactly right.

always use the real words unless you are talking anatomical parts, in which case you use the real word and define it right away.

[ER(notso)n00b, ASN, RN]

Ah, good point. I can't even remember what ended up happening with that care plan, but I went on to have several successful weeks after that.