Care Plan

Student: Trang Nguyen Date: 2/11/2019

Course: NSG-320 Instructor: Diane Garlick

Clincial Site: Banner Boswell Client Identifier: A.S Age: 97

Reason for Admission:

Patient came into the E.D with chief complaints of shortness of breath, congestive heart failure, and COPD exacerbation.

Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):

Acute respiratory failure with hypoxia Clincal manifestations will present as dhortness of breath, bluish
color on the skin, lips, and fingernails. A high carbon dioxide level
Acute hypoxemic respiratory failure can occur when the exchange and
can cause rapid breathing and confusion. Patients may become very
metabolic demand for oxygen fails. It can be caused by intrapulmonary
shunting of blood resulting from airspace filling or collapse. Cytokines sleepy or lose consciousness, and they also may develop
arrhythmias or irregular heartbeats.
will activate marcophages and neutrophils to the lungs, which will then
release leukotrienes, platelet-activating factors, and proteases. These
substances damage capillary endothelium and alveolar epithelium,
disrupting the barriers between capillaries and airspaces. Risk factors
include tobacco products, alcohol, family history of respiratory disease,
and a compromised immune system (Potter & Perry, 2017).

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 Assessment Data
Subjective Data:
Patient presented to the E.R with shortness of breath. She stated that she started getting shortness of breath the night of 1/25/2019. Patient had
previously been hospitalized 12/30/2018-1/06/2019 for pneumonia, UTI, and sepsis.

VS: T : 36.3 C Labs: Diagnostics:

BP: 171/62 2/11/2019 2/10/2019 Chest Single View Adult Portable X-Ray
HR: 67 o WBC: 6.0 M/MM3 5.7 M/MM3  Emphysematous changes in the
RR: 18 o RBC: 3.36 K/MM3 3.47 K/MM3 lungs. There are bilateral interstitial
o HGB: 11.4 g/dL 11.8 g/dL infiltrates. Bibasilar reticulonodular
O2 Sat: 98% on 2L/min of o HCT: 35.7% 36.7% pulmonary infiltrates. Atherosclerosis
Oxygen o MCHC: 31.9 g/dL 32.2 g/dL in thoracic aorta.
o MCV: 106 fL 106 fL
o RDW-CV: 15.2% 15% No other diagnostic tests, CT, MRI, etc.
o RDW-SD: 60.0% 58.7%
o Platelet: 233 K/MM3 229 K/MM3
o Sodium: 139 mmol/L 141 mmol/L
o Pot: 4.3 mmol/L 4.1 mmol/L
o Chloride: 103 mmol/L 102 mmol/L
o Glucose levels: 145 mg/dL 157 mg/dL
o BUN: 40.2 mg/dL 37.3 mg/dL
o Creatinine: 1.25 mg/dL 1.33 mg/dL
o BUN/Creatinine ratio: 32 28
o Calcium: 8.9 mg/dL 9.1 mg/dL
o Magnesium: 2.5 mg/dL 2.3 mg/dL
o CO2: 29 27

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The value of A.S’s RDW-CV and RDW-SD indicates that she
could have a nutrient deficiency, such as iron, folate, or
vitamin B-12. In order to a proper diagnosis, the HCP
provider needs to look at the MCV test to get a verfied
answer.

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Assessment: Orders:
Neurological assessment:  Mycoplasma antibodies lab
 Blood cultures
LOC: Alert and orientated x 4, responsive to all questions
 Delirium assessment
Speech: Clear, effortless, appropriate for conversation  Code status
Pupils: Equal, round, reactive to light, accommodation, and  Vital signs and weight
convergence bilaterally  Patient ambulates with assistance
 Respiratory oxygen through nasal cannula at flow rate of 2
Eyes: Equal, no drainage, no signs of jaundice, opens to verbal
L/min
commands
 Intake and output
Affect: Cooperative, appropriate for situation  Hospital acquired pneumonia precaution
Pupil size: 2mm bilaterally
Glasgow coma scale: 15

Skin
Color: Pink throughout
Status: Dry, intact, cool, no open lesions or sores
No tenting, skin turgor is appropriate for age
Findings: Multiple skin tags on the upper half of back. Skin tags are 1-
2cm wide and are a dark brown color.

Respiratory

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Oxygen Status: O2 Sat at 98% with oxygen at 2L/min
Lung sounds:

 Upper left lobe: course crackles

 Lower left lobe: course crackles
 Upper right lobe: diminished sounds
 Middle right lobe: course crackles
 Lower right lobe: diminished sounds
Cough: Able to clear secretions

MSK
Upper extremity motor response: Equal strength bilaterally, strong,
moves against resistance
Lower extremity motor response: Equal strength bilaterally, strong,
moves against resistance
Fall risk: 60 (high risk), gait is unsteady. Patient needs a walker to
ambulate and additional assistance.

Cardiovascular
Heart rate: 67 bpm
BP: 171/62
Heart sounds: S1, S2 auscultated, no S3 or S4 heard
Cardiac rhythm: sinus bradycardia, 1st degree heart block, bundle
branch block

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Pulses: Radial – palpable 2+ bilaterally pedal – palpable 1+ bilaterally
Capillary refill: Less than 3 seconds
No edema present upper or lower body

GI
Abdomen: non-distended, soft, non-tender
Bowel sounds: Normoactive in all 4 quadrants
Last bowel movement: 2/11/2019 at 10:38, stool was brown, solid, and
firm
Diet: Normal diet

Lines/IV
Peripheral IV: Left antecubital, 22 gauge
No phlebitis present

GU-Renal
Urine: Appeared very light yellow/clear. Urine was collected through a
bedside commode
Latest I/O collected: 2/11/2019 at 14:52
o Input: 450 mL
o Output: 300 mL

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 o Total Balance: 150 mL

Denies
Patient denies pain, burning, or difficulty

Pain/Nausea
Patient denies any current pain
Pain: 0/10

Endocrine (accuchecks)
145 on 2/11/2019
157 on 2/10/2019

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 Medications
ALLERGIES: No known allergies

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Pantoprazole 40 mg PO Once daily This is used to treat C. Difficile, abdominal pain, Assessment:
gastroesophageal reflux disease diarrhea, hypomagnesium if  Assess patient
and acid reflux. treatment is done x3 in a row, for epigastric
vitamin B12 deficiency or abdominal
(Vallerand & Sanowski, 2017) pain or occult
blood in stool
 Mayb cause
abnoral liver
function test –
elevated AST
and ALT
 Monitor serum
magnesium

Client teaching

 Teach patient
to notify HCP
if signs of
rash, diarrhea,
abdominal
cramping, or
fever
 Avoid alcohol
and NSAIDs
 Notify HCP if
taking OTC
medicine or
herbals

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 10 mg PO Once daily It can treat high blood pressure, Headache, peripheral edema, Assessment:
Felodipine reducing the risk of stroke and arrhythmias, heart failure,  Monitor ECG
heart attack. tachcardia, Stevens-Johnson periodically
syndrome (Vallerand &  Monitor intake
Sanowski, 2017) and output
 Assess for
signs of heart
failure

Client teaching:

 Teach patient
to notify HCP
immediately
when rash,
irregular
heartbeat, or
edema appears
 Educate the
patient on
signs of angina
 Patient needs
to comply to a
low sodium
diet in order to
manage
hypertension
Furosemide 20 mg PO Once daily This is a diuretic used treat Erythema, multiforme, toxic Assessment:
fluid retention and swelling epidermal necrolysis, aplastic  Assess fluid
caused by congestive heart anemia, agranulocytosis, status.
failure, liver disease, kidney hypotension (Vallerand & Monitor daily
disease Sanowski, 2017) weight, intake
and output
ratio
 Monitor BP
and pulse
before and

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 after
administration
 Assess fall risk
and
implement fall
preventions

Client teaching:

 Change
positions
slowly to avoid
orthostatic
hypotension
 Contact HCP if
you gain more
than 3 pounds
in a day
 Notify HCP if
you are about
to have
medicine
before surgery
40 mg = IV push Once daily This is a corticosteroid used to Deression, euphoria, peptic Assessment:
Methylprednisolone 1 mL treat inflammation, flare ups, ulcerations, hypertension, acne,  Assess for
and allergic reactions delayed wound healing, signs of renal
thromboembolism, weight gain insuffiency –
(Vallerand & Sanowski, 2017) hypotension,
vomiting,
confusion
 Assess LOC
and headache
during therapy
 Report positive
guaic-stool
tests

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 Client Teaching:

 Stopping the
medicine
aburptly will
will result in
aderenal
insuffiencies –
anorexia,
weakness
 Nform the
HCP if you
seen dark,
tarry stools
 Eat a diet high
in calcium,
protien, and
potassium
Lactobacillus Acidophilus 1 tab PO Once daily Probiotic therapy N/A N/A

100 mg PO Once daily Hypertension and angina Fatigue, weakness, bradycardia, Assessment:
Metoprolol heart failure, pulmonary edema, o Monitor BP,
erictile dysfunction, urinary ECG, and vital
frequency signs
(Vallerand & Sanowski, 2017) o Monitor intake
and output and
daily weights
o Assess for
angina

Client Teaching:

o Abrupt
withdrawl can
be fatal
o Teach patient
how to check
BP daily

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 o This
medication can
cause
drowsiness so
patient cannot
operate
machinery
(Vallerand & Sanowski,
2017)
10 mg = IV push PRN Lowering BP in hypertensive Tachycardia, angina, sodium Assessment:
Hydralazine 0.5mL patient in decreasing afterload retention, drug-induced, lupus  Monitor BP
with patient with heart failure syndrome, edema (Vallerand & and pulse
Sanowski, 2017) before and
after
administration
 Monitor CBC
and
electrolytes
during therapy
 May cause a
positive direct
Coombe test
result

Client teaching:

 Teach about
the importance
of medication
adherence, do
not double
dose
 Teach client to
manage
hypertensive
state – low
sodium diet
 Notify HCP of
any herbals or

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 OTC
medication

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 intervention Was goal met? Revise the
reasonable, and attainable. interventions. is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Impaired gas exchange related to acute respiratory failure with hypoxia as evidenced by the use of oxygen through a nasal
cannula
The patient will no longer need Continue to assess and record By monitoring patient, we can I was not there long enough
The goal is for the patient to be oxygen through a nasal cannula pulmonary status every 4 hours or assess any poor pulmonary to see if the goal could be
off the oxygen. and can breath using only room more frequently if patient’s status status that may lead to met. The goal would be met
air by the time of discharge in 2 is unstable hypoxemia if the patient’s respiratory
days. rate remains within healthy
Monitor vital signs and heart This is detect any tachycardia or limits, the patient can cough
rhythm at least every 4 hours tachypnea, which can indicate and clear sputum, the patient
hypoxemia can perform ADLs without
dyspnea.
Change patient position at least This is to mobilize secretions
every 2 hours and allow aeration of all lung
fields
(Phelps et al., 2017)

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Secondary Nursing Diagnosis:
Risk of impaired skin integrity related to impaired mobility as evidenced by unsteady gait and additional assistance
with walker
The goal is for the patient The patient will not show any Inspect the skin every 8 hours, The provides evidence of I was not there long enough to
maintain her skin integrity as is. evidence of skin breakdown for describe and document skin effectiveness of skin care see if the goal could be met.
the next 2 days up until conditions, and report changes regimen The goal wold be met if the
discharge, patient’s skin remains intact by
discharge and patient reports
Assist with general hygiene and This promotes comfort and a
feeling of comfort.
confort measures sense of well-being, and
reduced the likelihood of
infection

Change patient’s position every

2 hours, monitor turning and These measures reduce
skin condition pressure, promote ciruclation,
and minimize skin breakdown
(Phelps, et al., 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.”

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 References

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

PA: Wolters Kluwer Health.

Potter, P. A., RN, MSN, PhD, FAAN, Perry, A. G., RN, EdD, FAAN, Stockert, P., RN, BS. Fundamentals of Nursing. [VitalSource].

Retrieved from https://bookshelf.vitalsource.com/#/books/9780323327404/

Vallerand, A. H., & Sanowski, C. A. (2017). Davis’s Drug Guide for Nurses (16th ed.). Philadelphia, PA: F. A. Davis Company.

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