Care Plan

Student: Evelina Balzhyk Date: 9.2.2019

Course: NSG 320CC Instructor: Alyx Fergus

Clincial Site: Chandler Regional Hospital Client Identifier: JM Age: 82

Reason for Admission: Client was admitted to cardiology clinic for chest pain.

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

JM was diagnosed with NSTEMI on 8.29.19. JM’s clinical manifestations included pressure-like chest pain
which radiated to both arms, the neck, and the jaw. Pain lasted
According to NCBI, a NSTEMI is simply a mismatch in the myocardial
more than 10 minutes.
oxyden demand and myocardial oxygen consumption. A NSTEMI may be
produced by non-coronary injury to the heart such as cardiac contusion, Potential clinical manifestations include dyspnia, diaphoresis,
myocarditis, or presence of cardiotoxic substances. Onditions such as nausea or vomiting, syncope, and fatigue (Basit, 2019).
changes in blood pressure, tachycardia, aortic stenosis, and pulmonary
embolism may also lead to a NSTEMI (Basit, 2019).
Risk factors include: smoking, family history, hyperlipidaemia,
hypertension, and diabetes, renal insufficiency (Basit, 2019).

Assessment Data

Subjective Data: Patient stated that she had unusual pain at the moment. Pain included “discomfort in chest” and pain that radiated to arms,
neck, and jaw. Patient also stated that she had a heartburn and took Tums to treat it.
VS: T : 36.5 Labs: Diagnostics:
BP: 127/68 Glucose 123 (normal is <100 after not eating and XR chest
<140 two hours after eating)
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
 HR: 60 BUN 24 (normal 7-20) Atypical chest pain
RR:14 breaths/min Creatinine .9 (normal .6-1.2) Findings: cardiac silhouette is unremarkable. Minimal
O2 Sat: 96 on room air lilnear subsegmental atelectasis vs. scarring seen within
WBC 6.7 (normal 4,000-10,000)
right lung zone. Lungs demonstrate no focal consolidation,
Hct 39.7 (normal 37-48) pleural effusion or pneumothorax visualized, osseous
structures are grossly intact.
Hgb 13.7 (normal 12-15.5)

Assessment: Orders:
General: no acute distress  Consult to phase 1 cardiac rehab
 Lipid panel
Pt History: patient has a significant past history of hypertension and
hypercholesterolemia.  Cardiac monitor
 Heart healthy diet
Neuro: LOC alert and oriented to person and place, not to time.  Magnesium replacement monitoring
Pupils are equal, round. Pupil size is 3mm bilaterally. Eyes are  Ambulation
symmetrical. Conjunctiva is pink, sclera is white, bilaterally.  Physical therapy

Gait is a little weak and patient ambulates independently.

Negative Romberg test noted.
Respiratory:
Normal breath sounds are auscultated bilaterally. Good inspiratory
effort.
Respirations are regular, non-labored and even.
Chest is symmetrical, rising and falling of chest is symmetrical
Cardiovascular:
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Regular rate and rhythm, no lower extremity pitting edema bilaterally to
upper and lower extremities
S1 and S2 sounds noted, no S3/S4 sounds noted
Capillary refill < 3 seconds to bilateral fingers
Radial pulses 2+ bilaterally
BP is 127/68; HR is 60 bpm
Skin: no rash
bruising on left upper brachial. Puncture wound on right wrist.
Warm, dry, skin turgor is appropriate, color appropriate for ethnicity.
No upper body swellling noted bilaterally.
Musculoskeletal: Ambulates independently
ROM equal bilaterally to upper extremities with and without resistance.
Muscle weakness in flexion and extension of arm.
ROM equal bilaterally to lower extremities. Mild weakness in the knees
and lower extremities.
No swelling, redness, or nodules noted in the shoulder, elbow, wrist
joints bilaterally.
GU: voids without difficulty
GI: soft, non-tender, non-distended, bowel sounds are normal.
Continent urination and
Wound: bruising on left upper brachial. Puncture wound on right wrist.
Diet: heart healthy diet

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 Medications
ALLERGIES:
Epinephrine and neomycin

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect
Aspirin 325 mg po qd To treat atrial fibrillation Tinnitus, GI BLEEDING,
dyspepsia, epigastric
distress, nausea, abdominal
pain, anorexia,
hepatotoxicity, vomiting.
Hemat: anemia, hemolysis.
Derm: rash
(Vallerand, 2017).
25 mg po Qd Management of HTN fatigue, weakness, anxiety,
Atenolol depression, dizziness,
drowsiness, insomnia,
memory loss, blurred
vision, bronchospasm,
wheezing, bradycardia
(Vallerand, 2017).
Considerations
Patients who have
asthma, allergies,
and nasal polyps or
who are allergic to
tartrazine are at an
increased risk for
developing
hypersensitivity
reactions. Pain:
Assess pain and
limitation of
movement; note
type, location, and
intensity before and
at the peak after
administration. Side
effects: nausea,
vomiting, anemia,
abdominal pain
(Vallerand, 2017).
Monitor BP, ECG,
and pulse
frequently during
dosage
Monitor
intake/output ratios
and daily weights.
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 Assess routinely for
HF (dyspnea,
rales/crackles,
weight gain,
peripheral edema,
jugular venous
distention)
(Vallerand, 2017).
80 mg po Ghs Treatment of primary Constipation, diarrhea, Implement gradual
Pitavastatin hyperlipidemeia, to reduce increased liver enzymes, strengthening and
elevated total cholesterol rash, rhabdomyolysis, back other therapeutic
pain exercises to
(Vallerand, 2017). facilitate recovery
from muscle pain
and weakness.
(Vallerand, 2017).
7 tabs po Tid Treatment or prevention Headache, irritability, Assess for
Vitamin D of vitamin D deficiency conjunctivitis, symptoms of
photophpobia, arrhythmias, vitamin D
anorexia, constipation, dry deficiency prior to
mouth, bone pain, muscle and periodically
pain during assessment.
(Vallerand, 2017). Monitor serum
calcium
periodically
Observe for
hypocalcemia
(Vallerand, 2017).
75 mg po Qd Reduction of Depression, dizziness, Assess patients for
atherosclerotic events in fatigue, headache, symptoms of
Clopidogrel (Plavix) patients at risk for (MI, epistaxis, cough, dyspnea, stroke, peripheral
stroke, vascular death), chest pain, edema, vascular disease, or
including recent MI, ACS, hypertension, GI bleeding, MI periodically.

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 stroke, or PVD abdominal pain Monitor patient for
(Vallerand, 2017). signs of thrombotic
thrombocyctic
purpura.
(Vallerand, 2017).
5 mg po Qd Management of Dizziness, fatigue, cough, Monitor BP and
Lisinopril hypertension hypotension, chest pain, pulse frequently,
abdominal pain, diarrhea, monitor patient for
nausea, vomiting signs of
(Vallerand, 2017). angioedema
(dyspnea, facial
swelling)
(Vallerand, 2017).
500 mg po Qd Treatment of Drowsiness, low Monitor pulse, BP,
Magnesium gluconate hypomagnesemia, respiratory rate, respirations, ECG
treatment of hypertension arrhythmias, bradycardia, frequently,
hypotension, diarrhea, respirations should
muscle weakness be at least 16/min
(Vallerand, 2017). (Vallerand, 2017).
10 ml IV push Q12hrs Hydration and provision Pulmonary edema, edema, Assess fluid
Soidium chloride 0.9% of NaCl in deficiency hypernatremia, balance (intake and
states, maintenance of hypovolemia, hpokalemia, output, daily
electrolye and fluid status. irritation at IV site weight, edema, lung
Reconstitue or dilute other (Vallerand, 2017). sounds) throughout
medications. therapy. Assess
patients for
symptoms of
hyponatremia
(headache,
tachycardia, muscle
cramps, N/V) or
hypernatremia
(edema, weight

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 gain, hypertension)

(Vallerand, 2017).
1 tab po Qd Treatment and preventin Adverse reactions are Assess for signs of
Multivitamin of vitamin deficiencies extremely rare in nutritinoal
recommended doses. insufficiency before
Urine discoloration,allergic and during therapy.
reaction (Vallerand, 2017).
(Vallerand, 2017).
325 mg po PRN To decrease pain CNS: agitation, anxiety, Do not confuse
Acetaminophen headache, fatigue, Tylenol with
insomnia Resp: Tylenol PM. To
atelectasis, dyspnea CV: prevent fatal
hypertension, medication errors,
hypotension. GI: ensure dose in (mg)
hepatotoxicity, and (mL) is not
constipation (Vallerand, confused; and total
2017). daily dose of
acetaminophen
from all sources
does not exceed
maximum daily
limits. Common
side effects:
headache,
insomnia, anorexia,
nausea, vomiting
(Vallerand, 2017).
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 Was goal met? Revise
reasonable, and attainable. interventions. intervention is the plan of care
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 related to altered stroke volume as evidenced by blood pressure and pulse rate and rhythm.

This has been selected as a nursing diagnosis because cardiac output is a concern for physiological needs, which is the first tier in Maslow’s
Hierarchy of Needs.
Patient will experince no
chest pain.
Patient’s cardiac output
will remain adequate by
discharge.
1. Assess respiratory 1. Adventitious breath Goal was met.
status at least every sounds or dyspnea may 1. Patient’s respiratory
four hours. Report indicate fluid buildup in status was assessed
complaints of lungs and pulmonary every 4 hours. No
dyspnea or capillary bed. complaints of dyspnea
restlessness. 2. These may indicate present.
2. Report complaints of cerebral hypoxia resuslting 2. No complaints of
dizziness or from a cardiac rhythm dizziness or syncope
syncope. disturbance. were noted.
3. Give antiarrhythmic 3. To reduce or eliminate 3. Antiarrhythmic drugs
drugs as prescribed. arhythmias. were prescribed.

(Phelps, Ralph, &

Taylor, 2017). (Phelps, Ralph, & (Phelps, Ralph, &
Taylor, 2017). Taylor, 2017).

Secondary Nursing Diagnosis: Risk for falls related to decrease in lower extremity strength.

This has been selected as the secondary diagnosis because risk for falls is a concern for safety which is the second tier in Maslow’s Hierarchy of
Needs.
Patient will relate the JM will point out things in 1. Identify factors 1. To enhace the 1. Client stated
intent to use safety the environment that puts that may cause or patient, faily, caregiver factors that may
measures to prevent falls. her at risk for falls before contribute to injury awareness of the risks cause or contribute
discharge from a fall 2. Doing frequent to injury from a
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 2. Improve assessments of the fall.
environmental patient’s environment 2. Environmental
safety factors as is necessary to make safety factors were
needed sure new risks have improved as
3. Review not occurred needed
medications with 3. Two or more 3. Medicatinos were
patient and family. medications taken by a reviewed with
Help the patient patient put the patient patient and family.
understand which at greater risk. Many Patient understands
medications put the medications takken by which medications
patient at greater the elderly can cause can put the patient
risk for falls. dizziness, sleepiness, at a greater risk for
Knowing the risk lowered blood falls.
may help the pressure, and
patient take more confusion. Without (Phelps, Ralph, &
care in moving sufficient instructions, Taylor, 2017).
about. It may also the patient may at a
call for reviewing higher risk for falls.
with the primary
care physician.
(Phelps, Ralph, &
Taylor, 2017).
(Phelps, Ralph, & Taylor,
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
Basit, H. (2019, May 4). Non ST Segment Elevation (NSTEMI) Myocardial Infarction. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK513228/
Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10th ed.). Philadelphia, PA:
Wolters Kluwer.
Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis.

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