Care Plan

Student: Ahsan Arca Date: November 15, 2019

Course: NSG-320CC Instructor: Kelly Schaeffer

Clincial Site: St. Luke’s Tempe Hospital- MedSurg/Tele Unit Client Identifier: S.V. Age: 52

Reason for Admission: Client rushed to the ED after vomiting in the middle of the night, accompanied by extreme chest pain; she sustained
a heart attack from NSTEMI upon arrival. She was later transferred to this unit for obervation, especially to monitor the heart and
hypokalemia.

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

Heart attack: a sudden occurrence of stopping of the blood flow to the S.V. manifestations: tightness and pain sensation in the chest, N/V,
heart (“Mayo Clinic”, 2019). This occurs due to a narrowed heart vessel, and abdominal pain (“Mayo Clinic”, 2019).
typically from plaque that is made up of fat or cholesterol. The plaque Other C.M.: fatigue, SOB, and cold sweats (“Mayo Clinic”, 2019).
can break lose and dislodge into a bifurcation in the vessels of the heart,
blocking the blood flow (“Mayo Clinic”, 2019). Patient, S.V., sustained an
NSTEMI, which is a partial blockage of a heart vessel. Some risk factors
include: older age, smoking, high blood
pressure/cholesterol/triglycerides, stress, and drug use (“Mayo Clinic”,
2019).

Assessment Data

Subjective Data: “I drank alcohol and smoked pot for the first time in years”, claiming that she has been dealing with a lot of stress. Client
included that she had “chest pains and was vomiting when I woke up”; when asked about the initial pain level of her chest, she rated it an
“8/10” on numerical scale.

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

VS: Taken at 0800 Labs: Taken 11/15/19 at 0532 Diagnostics:

T : 36.4 C o WBC: 3,300 /mcL (normal 4,000-11,000) EKG: sinus tachycardia: HR 120bpm and NSTEMI found on
o RBC: 4,270,000 (normal 3,800,000- 11/14/19
BP: 145/87
5,000,000/mcL)
HR: 80bpm o Hgb: 13.1g/dL (normal: 11.7-17.3 g/dL)
RR: 16breaths/min o Hct: 37% (normal 35-50%)
o Platelets: 155,000/mcL (normal 150,000-
O2 Sat: 95% on RA 400,000)
Pain level: 4/10 on numerical o Potassium: 3.2 mmol/L (normal 3.5-5.0)
pain scale. *Potassium is decreased in people with
NSTEMI (Patel et al., 2017).
Taken at 1130
o Magnesium: 1.8mg/dL (normal 1.5-2.5)
T : 37.2C o Sodium: 140 mmol/L (normal 135-145)
BP: 149/86 o Phosphorus: unspecified
o Calcium: 8.7 mg/dL (normal 8.6-10.2 mg/dL).
HR: 84bpm o Glucose: 173mg/dL (normal 70-100)
RR: 16breaths/min *May be increased due to the nature of
being admitted to the hospital. Client is
O2 Sat: 98% on RA
stressed and has a decrease in physical
Pain level: 4/10 on numerical activity, which contribute to increase in
pain scale. blood glucose (Korytkowski, Umpierrez, &
McDonnell, 2019).
o CRE: 0.70 mg/dL (normal 0.2-1.0)
o BUN: 7 mg/dL (normal 6-20)
o GFR: >60mL/min/1.73m^2 (normal 90-
120mL/min/1.73m^2)
o ALT: 75 U/L (normal 10-40)

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o AST: 135 U/L (normal l7-56)

*Elevated AST is due to alcohol consumption.

AST is released into the bloodstream after
consuming an abundant amount of alcohol and
high amounts indicate liver damage (“Mayo
Clinic”, 2018).
o Amylase: unspecified
o Lipase: 186 U/L (normal 0-160)

*High lipase is an indication of acute

pancreatitis, directly related to high
consumption of alcohol (“AACC”, 2019).
o Albumin: 2.9 g/dL (3.4-5.4)

*Low albumin is a sign of liver disease, which

occurs after an abundance of alcohol intake
(“AACC”, 2019).
o Lactic Acid: unspecified
o Hemoglobin A1c: unspecified
o Troponin I: <0.070ng/mL (normal
<0.5ng/mL)
o PT: unspecified
o PTT: unspecified
o INR: unspecified
o Xa FACTOR: unspecified
o ABG’s: unspecified

Normal values reference (Lewis, Bucher,

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 Heitkemper, Harding, Kwong, & Roberts, 2017).

Assessment: Orders:
PMH: GERD, high cholesterol, HTN, & morbid obesity Full code
Height & weight: 5.0”; 96.1kg. Bedrest
Neuro: A&Ox 4 to person, place, time, and situation. Eyes open Cardiac monitoring
spontaneously b/l, and responds to verbal command and painful
Carb-controlled diet
stimuli. Pupils are brisk, equal, round, regular and approximately 3mm
b/l. Speech is very clear, she was calm, and cooperative.
Respiratory: Pt’s lung sounds were clear to auscultation, in all lobes
b/l. Repiratory is unlabored and oxygen status was normal, with O2 sat
at 98% on RA and respiratory rate at 16 bpm. Client was able to cough
on demand, but no spontaneous cough was noted.
Cardiovascular/vascular: No edema was noted. Capillary refill <3 sec.
Pulses in radial, posterior tibial, and pedal were present, but
diminished, approximately 1+ b/l. S1 and S2 heard upon auscultation,
with no murmurs or bruits noted.
GI: Abdomen was round, distended, and soft. Bowel sounds were
present and hypoactive. Last BM was on 11/15/19 at approximately
0920 and was non-watery and brown.
Drains: No drains were present.
GU: Client can void independetly. BRP was not restricted.
Skin: Skin color appropriate to ethnicity. Warm, dry, and skin intact. No
wounds were present.
Muscle skeletal: UE motor response was strong, equal, and moves
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against resistance, b/l. LE motor response was strong, equal, and
moves against resistance, b/l. Pt. ambulates independently, however,
her movements are slow. Client is not on fall precaution.
Diet: Carb-control diet. Appetite has been diminished since admission.
ADL/hygeine: Client is able to self-shower, perform oral care, pericare,
and skin care without assistance. Linens have not been changed since
admission on 11/14/19.
IV Access: 20G IV on the right AC. IV was patent, non-occlusive, and
dressing was clean, dry, and intact; dressing was recently changed at
0900 on 11/15/19.

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 Medications
ALLERGIES: Lisinopril, Oxycodone, and Penicillin.

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
chlordiazePOXIDE 50mg, 2 PO Q6h Used to treat alcohol Blurred vision, Instruct client not
(Librium) cap withdrawal (Vallerand & withdrawal, and rashes to abruptly stop
Sanoski, 2017). (Vallerand & Sanoski, medication, as
Therapeutic effect: 2017). withdrawal may
depresses the CNS, occur. Take with
“potentiating GABA” to meals/milk to
produce a sedative effect lessen GI effects.
or as an antianxiety Educate client
(Vallerand & Sanoski, about common s.e.
2017). such as,
drowsiness,
dizziness, and
weight gain
(Vallerand &
Sanoski, 2017).
40mg SQ daily Used to prevent VTE Bleeding, Assess pt. for signs
Enoxaprin (Lovenox) (Vallerand & Sanoski, thrombocytopenia, and of bleeding.
2017). hematoma (Vallerand & Change injection
Therapeutic effect: Sanoski, 2017). site to prevent
potentiates antithrombin ecchymosis.
effect (Vallerand & Monitor for
Sanoski, 2017). hypersensitivity
reactions. Common

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 s.e. include
headache,
insomnia, and
constipation
(Vallerand &
Sanoski, 2017).
40mg, 1 PO daily Used to prevent GERD CDAD, abdominal pain, Assess client for
Pantoprazole tab (Vallerand & Sanoski, and bone fracture abdomnial pain or
(Protonix) 2017). (Vallerand & Sanoski, bloody stools.
Therapeutic effect: “binds 2017). Monitor client’s
to an enzyme in the bowel
presence of acidic gastric sounds/function.
pH, preventing final Advise client to
transport of hydrogen abstain from
ions” (Vallerand & alcohol. Common
Sanoski, 2017, p.972). s.e. include
diarrhea,
hyperglycemia, and
headache
(Vallerand &
Sanoski, 2017).
650mg, 2 PO Q6h PRN Used for mild pain Hepatotoxicity, Stevens- Advise client to
Acetaminophen tab fever treatment (Vallerand & Johnson syndrome, and avoid alcohol while
(Tylenol) Sanoski, 2017). pancytopenia (Vallerand on therapy.
Therapeutic effect: blocks & Sanoski, 2017). Monitor client’s
the synthesis of temperature for
prostaglandins for effectiveness.
antypyresis effect Advise client to
(Vallerand & Sanoski, take ordered dose
2017). to avoid toxicity.
Common s.e.
include insomnia,
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 nausea, and
vomiting (Vallerand
& Sanoski, 2017).
4mg IV Q6h PRN Prevnts N/V. Serotonin syndrome, toxic Assess pt for N/V
Ondansentron (Zofran) N/V Therapeutic effect: blocks epidermal necrolysis, and and abdominal
receptor sites located in extrapyramidal symptoms pain. Assess for EPS
the vagal nerve terminals (EPS) (Vallerand & symptoms. Instruct
to decreases N/V Sanoski, 2017). client to report
(Vallerand & Sanoski, irregular heart beat
2017). to HCP. Common
s.e. include
headache,
constipation, and
diarrhea (Vallerand
& Sanoski, 2017).
20mEq IV PRN Used to treat potassium Arrhythmias, ECG Monitor client’s
Potassium chloride Piggyback hypokalemia loss. changes, and stenotic ECG. Instruct client
Therapeutic effect: lesions (Vallerand & to report black
maintains Sanoski, 2017). tarry stools. Assess
electrophysiologic for extravasation.
balance and acid-base Common s.e.
balance (Vallerand & include abdominal
Sanoski, 2017). pain, flatulence,
and diarrhea
(Vallerand &
Sanoski, 2017).
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
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 Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Decreased cardiac output r/t altered contractility of the heart, AEB sinus tachycardia found on EKG (Phelps, Ralph, & Taylor, 2017). This was
chosen the priority ND, as it plays role in blood circulation to the body and related to the priority nursing rule of “ABC’s”. Ability of blood to
flow adequately is also considered as a “basic need” in Maslow’s hierarchy of needs, being directly related to adequate distribution of oxygen
to the cells of the body. (Friberg & Creasia, 2016).
Client’s heart rate will be 1. “Extra heart sounds Goal was partially met.
Client will not present between 60-100bpm by 1. “Auscultate for may indicate early 1. Client was
rapid heart rate. the end of the shift. heart and breath cardiac assessed every 4
sounds at least decompensation; hours, especially
every 4 hours. adventitious breath heart and breath
Report abnormal sounds may sounds.
sounds” (Phelps, indicate pulmonary 2. Skin care was
Ralph, & Taylor, congestion” not provided.
2017, p.47). (Phelps, Ralph, & 3. Medication
2. “Provide skin care Taylor, 2017, p.47). administration
every 4 hours” 2. “To enhance skin was planned
(Phelps, Ralph, & perfusion and around client’s
Taylor, 2017, p.47). venous flow” schedule.
3. “Plan patient’s (Phelps, Ralph, &
activities” (Phelps, Taylor, 2017, p.47).
Ralph, & Taylor, 3. “to avoid fatigue
2017, p.47). and increased
myocardial
workload” (Phelps,
Ralph, & Taylor,
2017, p.47).
Secondary Nursing Diagnosis:
Ineffective coping r/t being overwhlemed with personal life problems, AEB claims of “drinking and smoking pot for the first time in years”

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(Phelps, Ralph, & Taylor, 2017).
Pt. will “communicate Client will verbalize two 1. “Arrange to spend 1. “Devoting time to Goal was partially met.
feelings about the present methods of healthy coping uninterrupted periods listening helps patient 1. Client was given time
situation” (Phelps, Ralph, mechanisms, such as of time with patient” express emotions, to express herself
& Taylor, 2017, p.76). meditation or guided (Phelps, Ralph, & grasp situations, and during times of
imagery, by the end of Taylor, 2017, p.77). cope effectively” uninterrupted periods.
shift. 2. “Help patient look at (Phelps, Ralph, & 2. Different outlook on
current situation and Taylor, 2017, p.77). current situation was
evaluate various 2. “to encourage a not provided for the
coping behaviors” realistic view of crisis” client.
(Phelps, Ralph, & (Phelps, Ralph, & 3. Client was reminded
Taylor, 2017, p.77). Taylor, 2017, p.77). of healthy ways to
3. “Teach patient 3. “Relaxation can assist cope with stress.
relaxation techniques to reduce anxiety and
of deep breathing and feelings of anger”
guided imagery” (Phelps, Ralph, &
(Phelps, Ralph, & Taylor, 2017, p.77).
Taylor, 2017, p.77).
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

AACC. (2019). Albumin. Retrieved from https://labtestsonline.org/tests/albumin

AACC. (2019). Lipase. Retrieved from https://labtestsonline.org/tests/lipase

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

Korytkowski, M., Umpierrez, G., & McDonnell, M. (2019). Hyperglycemia in the hospital. Hormone Health Network. Retrieved from

https://www.hormone.org/diseases-and-conditions/diabetes/hyperglycemia-in-the-hospital

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

Patel, R., Tannenbaum, S., Viana-Tejedor, A., Guo, J., Im, K., Morrow, D., & Scirica, B. (2017). Serum potassium levels, cardiac

arrhythmias, and mortality following non-ST-elevation myocardial infarction or unstable angina. US National Library of

Medicine, 6(1), 18-25. Doi:10.1177/2048872615624241

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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