Care Plan

Student: Ahsan Arca Date: October 7th, 2019

Course: NSG-320CC Instructor: Kelly Schaefer

Clincial Site: St. Luke’s Tempe Hospital; Medical-surgical unit Client Identifier: B.B. Room 220 Age: 25

Reason for Admission:

The client came to the hospital after “vomiting all morning” and feeling “nausea” before beginning his morning shift at work. Moreover,
the client was experiencing extreme abdominal pain, which lead him to seek care. The date of admission was 10/2/2019 at 1624.

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

Primary admitting diagnoses: alcoholic hepatitis. Some clinical manifestations of B.B. include: nausea and vomiting,
abdominal pain (rating the pain 8/10 on numerical scale), loss of
Alcoholic hepatitis is inflammation of the liver, caused by chronic alcohol
appetite, and fatigue/weakness throughout the body.
use. Alcohol contains dangerous chemicals that can accumulate in the
blood and processed by the liver (“Mayo Clinic”, 2018). As the liver cells Other signs and symptoms of clinical manifestations include: low
are constantly stimulated by these chemicals, they begin to deteriorate grade fever, ascites, and confusion/behavioral changes (“Mayo
until scars are created on the surface of the liver, eventually leading to Clinic”, 2018).
cirrhosis as the end stage of liver disease (“Mayo Clinic”, 2018). Risk
factors include: excessive alcohol intake- specifically consuming over 3.5
ounces of alcohol everyday for 20 years; women are more likely than
men; obese individuals who consume excess amounts of alcohol develop
cirrhosis faster due to the nature of the excess fat around the liver; and
race and ethnicity contribute to risk factors, with Blacks and Hispanics
being more vulnerable to the disease (“Mayo Clinic”, 2018).

Assessment Data
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
Subjective Data: Client reported, “I have severe pancreatitis. I had nausea and vomiting before I came to the hospital.”. When asked about
his abdominal pain the client rated the pain at an “8/10”.

VS: 10/4/19, 0800 Labs: taken 10/3/19 at 0543 Diagnostics:

T : 36.8 C BUN: 13 mg/dL (normal 6-20) U/S of liver was performed (date and time unspecified).
Results revealed mid-right sided pelviactasis,
BP: 118/79 Cr: 1.00 mg/dL (normal 0.2-1.0)
hemangioma in left lobe of liver, and hepatomegaly.
HR: 66 WBC: 4,100/mcL (normal 4,000-11,000)
RR: 16 Platelets: 389,000/mcL (normal 150,000-
O2 Sat: 96% RA 400,000)

10/4/19, 0130 Na+: 135 mmol/L (normal 135-145)

T : 37.1 C K+: 5.1 mmol/L (normal 3.5-5.0)

BP: 120/81 *An increase in potassium intake can be due to

HR: 72
RR: 16
O2 Sat: 97% RA
Pain: 8/10 on numerical pain
scale.
Quality: dull, intermittent pain
that is more apparent on the
LUQ of the abdomen.
Intervention: 2mg morphine.
IV push Q2h PRN for pain level
dehydration (“Mayo Clinic, 2018). Since the
client had been vomiting prior to admission,
dehydration occur as a result.
CO2: 19mmol/L (normal 22-29)
*Low CO2 may indicate low blood pH.
Metabolic acidosis can result from too much
alcohol in the blood (“Medline Plus”, 2019).
Glucose: 74 mg/dL (normal 70-100)
AST: 1289 U/L (normal 10-40)
ALT: 492 U/L (normal l7-56)
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of 7-10 was administered at
0715 and 1200. Client was
relieved of pain, rating the pain
4/10 on a numerical scale after
receiving medication.
Assessment:
PMH: alcohol abuse, HTN, and pancreatitis.
*Elevated AST and ALT are due to liver damage
from alcohol consumption. These enzymes are
released into the bloodstream and high
amounts indicate liver damage (“Mayo Clinic”,
2018).
Protein: 6.6 g/dL (normal 6-8.3)
Albumin: 3.3 g/dL (normal 3.4-5.4)
Globulin: 3.3 g/dL (normal 2-3.5)
Lipase: 87 U/L (normal 0-160)
There were no lab values for RBC, Hgb/Hct,
Mg2+. P, Ca2+, GFR, amylase, lactic acid, Hgb
A1C, Troponin-CKMB-BNP, PT/PTT, INR, Xa
Factor, and ABGs found in the patient’s (pt.)
chart.
Normal values reference (Lewis, Bucher,
Heitkemper, Harding, Kwong, & Roberts, 2017).
Orders:
 Clear liquids diet.
 Nutrition initial screen.
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Height and weight: 66 in. and 61.7 kg, repectively.  Sodium chloride 0.9% infusion; 100mL, 125mL/hr
 CMP.
Neuro: Client was A/Ox 4 to person, place, time, and situation. He had
 Consult gastroenterology.
a calm affect and was cooperative. His eyes opened spontaneously to
verbal command. His pupils were brisk, equal, round, and regular b/l
(bilaterally), approximately 5mm in size b/l.
Respiratory: lung sounds were clear to ausculation in all lobes, b/l.
Respirations were non-labored and oxygen status was WNL in RA.
Cardiovascular/vascular: no edema present in all extremities, b/l.
Capillary refill was <3 secs in UE & LE, b/l. Pulses were palpable and
normal, at approximately 2+ in radial and pedal pulses, b/l. Heart
sounds were regular in rhythm, with S1 and S2 present, and S3/ S4/
murmurs were absent.
GI: Abdomen is flat, round, and tender on the LUQ, non-distended, and
soft. Bowel sounds were present and hyperactive. Patient states that
N/V were present “yesterday”. Last BM was 10/3/19 at approximately
2200; description of BM was unable to be determined.
GU: Urine was unable to be examined during this time. Patient’s BRP
was not limited and he was able to ambulate to the BR independently.
Skin: patient’s skin is appropriate to ethnicity; no jaundice noted. His
skin was dry, intact, and warm. No wounds or ulcers noted.
Muscle skeletal: UE motor response was strong, equal, and moves
against resistance b/l. LE motor response was strong, equal, and moves
with resistance b/l. Patient ambulates independently, with no assistive
devive and no fall precations.
Diety: client is currently on clear liquids. His appetite is suppressed and

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he has “not been hungry lately”.
ADL/Hygeine: Client is able to perform ADLs independely and
performs self-care without assistance. Oral, pericare, and skin care are
self-assisted. Linens have not been changed since admission; however,
clear linens were implemented prior to admission on 10/2/2019 at
1600.
IV Access: 20 guage peripheral IV present in the right AC. It was patent
and the dressing was clean, dry, intact, and non-occlusive.

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 Medications
ALLERGIES: amLODIPine and Norvase

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
chlordiazePOXIDE 50mg; 2 PO QID Used for the Psychological or physical Assess the pt. BP
(Librium) cap management of alcohol dependence may occur, and RR, as well as
withdrawal syndrome. as well as seizures and mood. Assess pt.
Client is receiving it to muscle spasms (Vallerand for alcohol
prevent him from alcohol & Sanoski, 2017). withdrawal, such
withdrawal symptoms. as tremors and
Therapeutic effects: agitation. Teach
depresses CNS (Vallerand client to avoid
& Sanoski, 2017). alcohol use and
other CNS
depressants with
this med. Inform
client that daytime
sleepliness may
occur- avoid
activities that
require alertness.
Some s.e. include
insomnia and
drowsiness
(Vallerand &
Sanoski, 2017).
1mg; 1 PO Once daily Used for prevention of Fever, rash, and malaise Assess B.B. for

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Folic acid (Apo-Folic) tab anemias. Pt. is receiving it (Vallerand & Sanoski, signs of
as he is at risk for 2017). megaloblastic
developing anemia anemias and drug
because his kidneys may interaction, such as
not be functioning as well extreme
due to excess alcohol drowsiness from
intake, therefore, EPO the effects of other
hormone release may be drugs he is
inadequate. currently taking.
Therapeutic effects: Educate about
restores normal other food
hematopoiesis (Vallerand products high in
& Sanoski, 2017). folic acid such as
vegetables and
fruits. Some s.e.
include difficulty
sleeping and
irritability
(Vallerand &
Sanoski, 2017).
100mg; 1 PO Once daily To prevent beriberi. Vascular collapse, Assess client’s
Thiamine (Betaxin) tab Client is on this to angioedema, and nutritional status
suplement his diet, as pulmonary edema and monitor
alcoholism can result in (Vallerand & Sanoski, improvement of
inadequate thiamine in 2017). certain deficiencies
the body. he may have.
Therapeutic effect: Educate pt. about
“replace deficiency foods high in
states” (Vallerand & thiamine, such as
Sanoski, 2017, p. 1191). whole grain cereals
and pork. Teach
the client to spread
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 out activities to
enhance rest.
Some s.e. include
restlessness,
weakness, and
hypotension.
3mL Inhaln Q4hr PRN “Maintenance therapy of Bronchospasm, epistaxis, Assess client’s
Ipatropium (Atrovent) SOB reversible airway and blurred vision respiratory status
obstruction” (Vallerand & (Vallerand & Sanoski, before
Sanoski, 2017, p. 709). 2017). administration.
Patient is on this to Educate client
resolve intermittent SOB. regarding mouth
Therapeutic effect: care after
“inhibits cholinergic inhalation to
receptors in bronchial prevent dry mouth.
smooth muscle” Some s.e. include
(Vallerand & Sanoski, dizziness,
2017, p. 709). headache (HA),
and nausea
(Vallerand &
Sanoski, 2017).
0.5-4mg IV Push PRN Q4h To decrease anxiety. Apnea, cardiac arrest, Assess client’s level
Lorazepam (Ativan) Client is receiving this to and rashes. of anxiety and
reduce his general mental status
anxiety. throughout
Therapeutic effect: therapy. Educate
depresses CNS by client regarding
potentiating GABA the short-term
(Vallerand & Sanoski, treatment of this
2017). medication; teach
other ways to
decrease anxiety,
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 such as exercise.
Some s.e. include
dizziness, lethargy,
amd HA (Vallerand
& Sanoski, 2017).
2mg IV push Q2h PRN pain To reduce severe pain. Pt. Respiratory depression, Assess the client’s
Morphine 7-10 experiences constant hallucinations, and pain using PQRST
(Astamorphe) abdominal pain. “floating” feeling and assess
Therapeutic effects: (Vallerand & Sanoski, intensity prior to
decreases severity of pain 2017). administration.
by binding to “opiate Educate the client
receptors” in the CNS to slowly rise
(Vallerand & Sanoski, before getting out
2017). of bed to reduce
orthostatic
hypotension. Warn
client regarding
the use of alcohol
and its interaction
with morphine.
Some s.e. include
confusion.
Sedation, and
constipation
(Vallerand &
Sanoski, 2017).
4mg IV psuh Q6h PRN To prevent N/V. Client Serotonin syndrome, Assess the client’s
Ondansetron (Zofran) nausea was experiencing Torsade de Pointes, and bowel sounds prior
extreme N/V prior to Stevens-Johnson to administration.
admission. Therapeutic syndrome (Vallerand & Teach the client to
effects: “blocks the Sanoski, 2017). take this as
effects of serotonin at 5- directed and check
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 HT3 receptor sites”, for involuntary eye
reducing the severity of movements, which
N/V (Vallerand & Sanoski, should be reported
2017, p.933). to the HCP. Some
s.e. include HA,
fatigue, and
weakness
(Vallerand &
Sanoski, 2017).
20mEq IV PRN To treat potassium Arryhthmias, paralysis, Monitor pt. for s/s
Potassium chloride piggyback hypokalemia depletion. Client is taking and paresthesia of hypokalemia,
(Klor-Con) over 2 hrs this due to prior low (Vallerand & Sanoski, such as weakness
potassium levels upon 2017). and polydipsia.
admission. Therapeutic Educate pt. how to
effects: maintains acid- read labels on food
base balanc eand products to
activates enzymes to manage K+
solve deficiency imbalance. Some
(Vallerand & Sanoski, s.e. include
2017). abdominal pain,
restlessness, and
weakness.
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time- Nursing or interprofessional Provide reason why Was goal met? Revise
specific, reasonable, and interventions. intervention is the plan of care
attainable. indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis).
Imbalanced nutrition: less than body requirements r/t LUQ pain, AEB the need for vitamin/electrolyte supplements (Phelps, Ralph, & Taylor,
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2017). This was chosen as the priority diagnosis, as food is included in the basic physiological needs of life, according to Maslow’s hierarchy of
needs (Friberg & Creasia, 2016).
Patient will be able to list 1. Collaborating with the The goal was partially
Patient will demonstrate nutritious meals to make 1. “Reinforce the medical client enhances met.
ability to plan diet (Phelps, for breakfast, lunch, and regimen by explaining compliance to patient’s 1. Client’s current
Ralph, & Taylor, 2017). dinner, before discharge to patient and family care (Phelps, Ralph, & vitamin
at 1500. members the reasons Taylor, 2017). supplements
for the present 2. Encourages client to were explained
regimen” (Phelps, participate in care the need for
Ralph, & Taylor, 2017, (Phelps, Ralph, & intake prior to
p.231). Taylor, 2017). administration.
2. Teach the client the 3. Reinforces the client to 2. The priniciples of
“principles of good look for food items good nutrition
nutrition” that is that are high in was not
specific for the client’s nutritional values. explained to the
condition (Phelps, client.
Ralph, & Taylor, 2017). 3. Food labels were
3. Teach client how to shown to client
read food labels and upon receiving
what nutrients to focus his food tray.
on in food items.

Secondary Nursing Diagnosis: Risk for impaired liver fumction r/t high AST and ALT levels (Phelps, Ralph, & Taylor, 2017).

Patient will verbalize ways 1. “Monitor for 1. “To notify The goal was partially
“Patient will modify decrease alcohol intake to clinical physician onnorder met.
lifestyle and risk one drink a day or every manifestations of to initiate 1. Client’s abdomen
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behaviors” (Phelps, Ralph,
& Taylor, 2017, p. 207). shift.
two days by the end of the hepatic treatment if liver was assessed for
inflammation and function is pain in all four
dysfunction” compromised” quadrants.
(Phelps, Ralph, & (Phelps, Ralph, & 2. Information
Taylor, 2017, p. Taylor, 2017, p. regarding
207). 207). counseling was not
2. “Refer patient to 2. “Modification of provided.
counseling and risk behaviors will 3. Therapeutic
therapy to address provide risk communication
lifestyle choices avoidance for drug regarding the use
and risk behaviors” and alcohol abuse” of alcohol was
(Phelps, Ralph, & (Phelps, Ralph, & implied during
Taylor, 2017, p. Taylor, 2017, p. interaction with
207). 207). client.
3. “Provide a 3. “Promote feelings
nonjudgemental of self-worth”
attitude toward (Phelps, Ralph, &
patient’slifestyle Taylor, 2017, p.
choices” (Phelps, 207).
Ralph, & Taylor,
2017, p. 207).

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

Friberg, E. E., & Creasia, J. L. (2016). Conceptual foundations: The bridge to professional nursing practice (6th ed.). St. Louis, MO.

Lewis, S., Bucher, L., Heitkemper, M., & Harding, M. (2017). Medical-surgical nursing (10th ed.). St. Louis, MO.

Mayo Clinic. (2018). Alcohol hepatitis. Retrieved from https://www.mayoclinic.org/diseases-conditions/alcoholic-hepatitis/diagnosis-

treatment/drc-20351394

Mayo Clinic. (2018). Hyperkalemia. Retrieved from https://www.mayoclinic.org/symptoms/hyperkalemia/basics/causes/sym-

20050776

Medline Plus. (2019). Carbon dioxide (CO2) in blood. Retrieved from https://medlineplus.gov/lab-tests/carbon-dioxide-co2-in-blood/

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD.

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Vallerand, A., & Sanoski, C. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA.

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