Med-Surg Care Plan

Student: Selina Dykes Date: 2/13/2020

Course: NSG320 Instructor: McNiff

Clincial Site: Banner University Client Identifier: I.A. Age: 70

Reason for Admission:

Patient came in complaining of chest pain and dyspnea. Patient was also found to have an AKI, UTI, GAD, anemia and hypoglycemia.

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

I.A. has a medical diagnosis of pulmonary edema and congestive heart
failure.
Pulmonary edema is a condition where there is excess fluid in the lungs.
This fluid collects in the air sacks (alveoli) in the lungs which makes it
hard to breathe. This is because the alveoli are responsible for the
exchange of gases and a person who has pulmonary edema cannot
transfer the air due to the fluid blocking the alveoli. This is typically
caused by heart problems and in I.A.’s case, caused by the CHF. (Mayo
Clinic, 2018). Risk factors for pulmonary edema include
 History of pulmonary edema
 History of lung disease such as TB or COPD
 Vascular blood disorders
 (Mayo Clinic, 2018).
The other medical diagnosis for I.A was congestive heart failure of CHF.
This can occur in a patient whose heart muscle is not pumping blood
Expected manifestations of pulmonary edema are: coughing up
blood, difficulty breathing, paroxysmal nocturnal dyspnea,
wheezing sounds, pale skin, sweating and problems speaking due to
shortness of breath. (Medline Plus Medical Encyclopedia, 2020).
Observed patient manifestations: Patient was short of breath upon
arrival and while trying to talk. Patient had a cough but no sputum
or blood was present. Patient was sweating and looked like she was
hyperventilating trying to get air.
Expected manifestations for CHF: shortness of breath, persistent
coughing, buildup of excess fluid in body tissues called edema,
tired, fatigued, confused, lack of appetite, increased heart rate.
(American Heart Association, 2019).
Observed patient manifestations: As stated above, patient was short
of breath while talking and lying. Patient had lower body edema in
the ankles, patient seemed to be confused and forgetful when given

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normally. This can be caused by narrowed arteries 0f high blood pressure, instructions and information. Patient was also complaining of being
making the heart weak. This can also happen if the heart becomes too stiff tired but could be due to long transport ride since she live in Ajo,
and not fill properly. (Mayo Clinic, 2017). Some risk factors for CHF Az.
include
 High blood pressure
 Coronary artery disease
 Heart attack
 Diabetes
 Medications
 Tobacco and alcohol use
 Sleep apnea
 (Mayo Clinic, 2017).

Assessment Data
Subjective Data:
Patient complains of pain and difficulty breathing, she is diaphoretic and say she has a headache. Patient says her pain is at a 6 when trying to
breathe. Patient also states that she has a persistent cough for a week and has chest pain. Patient says she is anxious and nauseous and wants to
go home.
VS: T : 36.9 Celcius Labs: Diagnostics:
BP: 138/65 mmHg WBC  9.3 K/MM3 Chest single view: cardiac size is normal with
arteriosclerotic change in the arch (2/4/2020 at 0945 in
HR: 78 BPM RBC  2.70 M/MM3 cath lab)
RR: 18 br/min Hgb  7.6 g/dL
O2 Sat: 98 on RA
HCT  24.7% L
Vitals were taken on 2/10/2020
at 0733 BG  0150 am: 135, 0319 am: 47, 0739 am:
178, 1238 pm: 378

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 *BG is fluctuating too much to be discharged*

Assessment: Orders:
Neuro: A&O x3, speech is clear, patient is confused, PERRLA, affect  Education: dysphagia
is alert.  Aspiration precaution
Respiratory: O2 is 98% on RA, lungs: left lobe is diminished, effort:  Saline lock IV
labored with cough but no sputum.  Cardiac monitoring
 Education: Delirium
Cardiovascular: Regular rate and rhythm, pulse is 2+ in radial and  PT,OT and speech therapy
dorsal pedis, capillary refill in >3 seconds, edema is present in both
ankles and feet.
GI: Abdomen is flat and nontender, last BM was on 2/9/2020, bowel
sounds are nomoactive, diet is normal consistency on cardiac diet.
GU: No catheter present, urine is clear and pale yellow.
Skin: Color is appropriate for ethinicity, warm and intact, has no open
wounds but large bruise on right arm from cath lab.
Hygeine: Patient is clean and well kept, 100% oral care and bathing
care, self ambulating.

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 Medications
ALLERGIES:
NKDA
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Atorvastatin 40 mg PO Qhs Primary prevention of Adverse effects include chest Monitor liver
cardiovascular disease pain, peripheral edema, flatus, function tests (AST
(decrease risk of MI or heartburn, elevated liver & ALT) before
stroke) in patients with enzymes and rhabdomyolysis initiating therapy
multiple risk factors for (Vallerand, Sanoski, & and if signs of liver
coronary heart disease Deglin, 2017). injury (fatigue,
CHD or type 2 diabetes anorexia, right
mellitus. Lowers total and upper abdominal
LDL cholesterol and discomfort, dark
triglycerides. Slightly urine or jaundice)
increase HDL (Vallerand, occur. Avoid large
Sanoski, & Deglin, amounts of
2017). grapefruit juice
during therapy;
may increase risk
of toxicity
(Vallerand,
Sanoski, & Deglin,
2017).
Levothyroxine 100 mcg PO QMorning Thyroid supplementation Angina pectoris, arrhythmias, Assess apical pulse
in hypothyroidism. tachycardia, heat intolerance, and BP prior and
(Vallerand, Sanoski, & insomnia, weight loss. during
Deglin, 2017). (Vallerand, Sanoski, & administration to
Deglin, 2017). monitor any chest
pain or
tachyarrhythmias.
Monitor thyroid
function tests prior
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 and during
administration.
(Vallerand,
Sanoski, & Deglin,
2017).
Nifedipine 60 mg PO Daily Management of HTN, HA, abnormal dreams, Monitor BP and
angina pectoris, can also anxiety, confusion, peripheral pulse periodically.
prevent migraines. It edema, arrhythmias, Monitor intake and
works by inhibiting drowsiness, cough, dyspnea, output and daily
calcium transport into Steven-Johnsons Syndrome, weights. Assess for
myocardial and vascular photosensitivity. signs of HF. Assess
smooth cells, resulting in (Vallerand, Sanoski, & for rash.
inhibition of excitation- Deglin, 2017). (Vallerand,
contraction coupling and Sanoski, & Deglin,
subsequent contraction. 2017).
(Vallerand, Sanoski, &
Deglin, 2017).
Albuterol 2.5 mg Nubulized Q6H Used as a bronchodilator Restlessness, tremor, Assess lung sounds,
to control and prevent headache, chest pain and pulse and BP
reversible airway palpitations, hyperglycemia. before
obstruction. TE: (Vallerand, Sanoski, & administering
bronchodilation Deglin, 2017). Monitor pulmonary
(Vallerand, Sanoski, & function tests
Deglin, 2017). before therapy.
Observe for
paradoxical
bronchospasm
(wheezing).
(Vallerand,
Sanoski, & Deglin,
2017).
Haloperidol 1 mg IVP Q6H Acute and chronic Seizures, extrapyramidal Assess mental
psychotic disorders reactions, blurred vision, dry status, monitor BP,

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 including schizophrenia eyes, respiratory depression, monitor intake and
and manic states. TE: constipation dry mouth. output, monitor
diminished signs and (Vallerand, Sanoski, & patient for onset of
symptoms of psychoses. Deglin, 2017). akathisia.
Improved behavior in
children with Tourette’s (Vallerand,
syndrome or other Sanoski, & Deglin,
behavioral problems. 2017).
(Vallerand, Sanoski, &
Deglin, 2017).
Insulin: Glargine 10 units SQ Qhs Control of hyperglycemia Hypoglycemia, hypokalemia,
in patients with type 1 or lipodystrophy, pruritis, Assess patient for
type 2 diabetes mellitus.  erythema, swelling, allergic signs and
(Vallerand, Sanoski, & reactions including symptoms of
Deglin, 2017). ANAPHYLAXIS.  hypoglycemia 
(Vallerand, Sanoski, &
Deglin, 2017). Administer
insulin glargine
once daily at the
same time each
day.  (Vallerand,
Sanoski, &
Deglin, 2017).

Atropine 0.5 mg IVP PRN Given to preoperatively Drowsiness, confusion, Assess vital signs
to decrease oral and blurred vision, tachycardia, and ECG tracings,
respiratory secretions, palpitations, urinary hesitancy. monitor input and
treatment of sinus (Vallerand, Sanoski, & output, assess for
bradycardia and heart Deglin, 2017). abdominal
block. TE: Increased distention and
heart rate, decreased GI auscultate bowel
and respiratory sounds.
secretions. (Vallerand,
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 (Vallerand, Sanoski, &
Deglin, 2017).
Metoprolol 50 mg PO BID Hypertension, angina
pectoris, prevention of
MI and decreased
mortality in patients with
a history of MI. Decrease
BP and heart rate,
decreased frequency of
attacks and angina
pectoris.
(Vallerand, Sanoski, &
Deglin, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s)
Client or family focused. Measurable, time-specific, Nursing or interprofessional
reasonable, and attainable. interventions.
Sanoski, & Deglin,
2017).
CNS: fatigue, weakness, Assess frequency
anxiety, depression and characteristics
CV: bradycardia, HF, of anginal attacks
pulmonary edema throughout therapy.
GU: erectile dysfunction Abrupt withdrawal
(Vallerand, Sanoski, & may precipitate
Deglin, 2017). life-threatening
arrhythmias, HTN,
or MI. Notify HCP
if patient
experiences slow
pulse, difficulty
breathing,
wheezing, cold
hands and feet,
dizziness,
lightheadedness,
confusion,
depression, rash,
fever, sore throat,
unusual bleeding or
bruising.
(Vallerand,
Sanoski, & Deglin,
2017).
Rationale Evaluation
Provide reason why intervention Was goal met? Revise the
is indicated/therapeutic. plan of care according the
Provide references. client’s response to current
plan of care.
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Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Decreased Cardiac output related to reduced myocardial perfusion
Patient will be able to Patient will tolerate Monitor for dyspnea or Older patients with silent Patient did meet goal of
recognize when she is out exercise and activities at breathlessness every 2-4 or painless myocardial recognizing when she
of breath when exercising. usual level, taking into hours and report changes infarction frequently was out of breath.
account any cardiac from baseline. develop dyspnea related to Although she was not
damage by end of shift. left sided heart failure. necessarily exercising,
he walked around the
nurses station and was
able to recognize.

Patient will be free from
pain related to shortness of
breath and headaches.
Patient won’t experience Monitor mental status every Dizziness, confusion, light Patient said that
tachpnea, restlessness, 2-4 hours and report headedness and headache and shortness
anxiety, dyspnea, deviations from baseline. resltessness may indicate of breath was relieved
confusion, fainting, dizzy decreased cerebral blood after taking morning and
spells, light headedness, flow caused by slow 2 pm medications which
nausea, fatigue or carotid sinus reflex. made the goal met.
weakness by end of day.

(Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor, (Phelps, Ralph, &
2017). 2017). 2017). Taylor, 2017).
Secondary Nursing Diagnosis:
Excess fluid volume related to compromised regulatory mechanism.
Patient will exercise 30 Patient’s blood pressure Monitor blood pressure, Changed prameters may Patient did meet goal of
minutes today to initate and vital signs will be pulse rate, heart rhythm, indicated altered fluid or exercising today for 30
postive habits to lower within normal limits by temperature and breath electrolyte status. minutes by walking
blood pressure. end of day. sounds at least every 4 around the nursing station
hours, record and report and hallways.
changes.

Learn patient’s food

Patient will be able to Patient will demonstrate This enhances dietary
preferenes and plan
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verbalize appropriate skill in selecting permitted
foods to eat on a cardiac foods such as those low in
diet. sodium and potassium by
end of shift.
(Phelps, Ralph, & Taylor,
2017).
accordingly within compliance by finding
prescribed dietary food that the patient likes
restrictions. but is also acceptable to
eat under the
circumstances.
(Phelps, Ralph, & Taylor,
(Phelps, Ralph, & Taylor,
2017).
2017).
Patient did meet goal of
verbalizing which foods
were allowed to eat under
the cardiac diet when
speaking to her after
lunch.
(Phelps, Ralph, & Taylor,
2017).
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 References
American Heart Association. (2019). Warning signs of heart failure. Retrieved from https://www.heart.org/en/health-topics/heart-

failure/warning-signs-of-heart-failure

Mayo Clinic. (2017, December 23). Heart Failure. Retrieved from https://www.mayoclinic.org/diseases-conditions/heart-

failure/symptoms-causes/syc-20373142

Mayo Clinic. (2018, August 8). Pulmonary edema. Retrieved from https://www.mayoclinic.org/diseases-conditions/pulmonary-

edema/symptoms-causes/syc-20377009

MedlinePlus Medical Encyclopedia. (2020). Pulmonary edema. Retrieved from https://medlineplus.gov/ency/article/000140.htm

Vallerand, A. H., Sanoski, C. A., & Delgin, J. H. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia, PA: F. A. Davis.

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