Medsurg Careplan 3

Med-Surg Care Plan
Student: Samantha Wiederkehr Date: 02-24-20
Course: 320CC Instructor: Professor McNiff
Clincial Site: Banner University Medical Center Client Identifier: R.E. Age: 44
Reason for Admission: Shortness of breath; patient has been experiencing SOB for 2 weeks and 2 days before being admitted he noted that it
was getting increasingly worse. He also reported feeling dizzy and lightheaded upon admission.
Medical Diagnoses: (Include Pathophysiology and Risk Factors): Clinical Manifestation(s):
Heart failure: Heart failure “is a complex clinical syndrome that develops R.E. presented with difficulty breathing, shortness of breath,
in response to myocardial injury and results in decreased heart function” edema, fatigue, atrial flutter, a cough, feelings of dizziness,
(Harding, Roberts, Reinisch, Hagler, & Kwong, 2020, p.734). It leads to the rhonchi, and an ejection fraction of 27%.
heart lacking the ability to meet the oxygen needs of tissues. Some risk
factors include high blood pressure, CAD, heart attack, diabetes, obesity,
and irregular heart beats. Common symptoms of chronic heart failure include fatigue,
dyspnea, cough, palpitations, edema, neurologic manifestations
Pneumonia: Pneumonia occurs from pathogens that lead to an (dizziness, lightheadedness, etc.), sleep problems, chest pain, and
inflammatory response within the lungs. In response, “the inflammatory weight changes (Harding, Roberts, Reinisch, Hagler, & Kwong, 2020,
process attracts more neutrophils, edema of the airways occurs, and fluid p. 739-740).
leaks from the capillaries and tissues into alveoli” (Harding, Roberts,
Reinisch, Hagler, & Kwong, 2020, p.505). This leads to the clinical
manifestations that are seen such as hypoxia, cough, and dyspnea. Risk
factors of pneumonia include age (<2 or >65), chronic disease, or
smoking.
© 2019. Grand Canyon University. All Rights Reserved.

Assessment Data
Subjective Data: R.E. denies any pain and says that he just wants to eat and asked when he would be able to.
VS: @1200 Labs: Diagnostics:
T: 36.5 ° C WBC: 32.3 Ejection fraction: 27%
BP: 113/76 HgB: 18.1
HR: 79 PT: 18.3
RR: 18 INR: 1.6
O2 Sat: 95% RA
Assessment: Orders:
Neurological: A&O x4, Glasgow coma scale: 15 FULL CODE
HENT: normocephalic; pupils are round, equal, and reactive to light; NPO
pupils are approximately 3mm bilaterally
Vitals q4h
Respiratory: dry, occasional, spontaneous cough; breaths are unlabored; Atrial fibrillation ablation (02-26-20)
breath sounds are diminished in all lobes bilaterally
AICD placement (date not determined)
Cardiovascular: capillary refill less than 2 seconds bilaterally; radial and
dorsalis pedis pulses are 2+ bilaterally, not easily obliterated
GI: bowel sounds present in all 4 quadrants; abdomen is protuberant,
rounded, and non-tender upon palpation; abdomen has non-pitting
generalized edema noted
GU: voids without difficult; uses a urinal
Skin: skin is warm and dry bilaterally;color is appropriate for ethnicity;
braden score: 18
2
Medications
ALLERGIES:
No known drug allergies
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Albuterol-ipratropium 3mL Nebulized Q4h Bronchodilator. Binds to beta2- CNS: nervousness, restlessness, Assess lung sounds,
adrenergic receptors in airway tremor, HA, insomnia pulse, and BP before
smooth muscle, relaxing the Resp: paradoxical administration and
muscle and causing bronchospasms during peak of
bronchodilation. (Vallerand, CV: chest pain, palpitations, medication. Monitor
Sanoski, & Deglin, 2017). angina, arrhythmias, pulmonary function
hypertension tests. Observe for
GI: nausea, vomiting paradoxical
Endo: hyperglycemia bronchospasms.
F & E: hypokalemia (Vallerand, Sanoski, &
(Vallerand, Sanoski, & Deglin, Deglin, 2017).
2017).
Arformoterol 15mcg Nebulized BID Maintenance treatment to CNS: headache, insomnia, Assess lung sounds,
prevent bronchospasm in nervousness, weakness pulse, and BP before
COPD. Produces accumulation Resp: asthma-related death, administration, monitor
of cAMP at beta-adrenergic paradoxical bronchospasm pulmonary function
receptors causing CV: ECG changes, tachycardia tests, and observe for
bronchodilation (Vallerand, GI: vomiting paradoxical
Sanoski, & Deglin, 2017). Derm: rash bronchospasms
F&E: hypokalemia (Vallerand, Sanoski, &
Hemat: leukocytosis Deglin, 2017).
MS: cramps
Neuro: tremor
(Vallerand, Sanoski, & Deglin,
2017).
Aspirin 81mg PO Daily Treatment of inflammatory EENT: tinnitus Assess pain and
disorders , pain, fever, and GI: GI bleeding, limitation of movement,
prophylaxis of TIAs and MI. dyspepsia,epigastric distress, assess fever and note
reduces inflammation and nausea, abdominal pain, associated signs,
fever, decreases incidence of anorexia, hepatotoxicity, monitor hepatic
TIAs and MI, and analgesia. vomiting function before
3
(Vallerand, Sanoski, & Deglin, Hemat: anemia, hemolysis antirheumatic therapy,
2017). Derm: rash, urticaria monitor serum
Misc: allergic reactions salicylate levels, and
including anaphylaxis and monitor for signs of
laryngeal edema toxicity (Vallerand,
(Vallerand, Sanoski, & Deglin, Sanoski, & Deglin,
2017). 2017).
Atorvastatin 20mg PO Every Adjunctive management of CNS: amnesia, confusion, Assess patients diet
evening primary hypercholesterolemia dizziness, headache, insomnia, history, evaluate serum
and mixed dyslipidemia. memory loss, weakness cholesterol and
Lowers total and LDL EENT: rhinitis triglyceride levels,
cholesterol and triglycerides Resp: bronchitis monitor liver function
(Vallerand, Sanoski, & Deglin, CV: chest pain,peripheral edema tests, monitor patients
2017). GI: abdominal cramps, CPK levels if they
constipation, diarrhea, flatus, develop muscle
heartburn tenderness during
GU: erectile dysfunction therapy (Vallerand,
Derm: rashes and pruritus Sanoski, & Deglin,
MS: rhabdomylosis, arthralgia, 2017).
arthritis
2017).
Budesonide 0.5mg Nebulized BID Maintenence treatment and CNS: headache Monitor respiratory
prophylactic therapy of asthma. Derm: rash status and lung sounds,
Decreases frequency/severity of EENT: otitis media, dysphonia, assess pulmonary
asthma attacks and improves epistaxis, oropharyngeal fungal function tests, caution
asthma symptoms (Vallerand, infections, pharyngitis, rhinitis, patient to avoid
Sanoski, & Deglin, 2017). sinusitis smoking, and advise
Resp: bronchospasm,cough patient to notify HCP is
GI: abdominal pain, diarrhea, experiencing sore
dyspepsia, gastroenteritis, throat/mouth
nausea, vomiting (Vallerand, Sanoski, &
Endo: adrenal suppression, Deglin, 2017).
weight gain
MS: back pain
2017).
Carvedilol 12.5mg PO BID w/ Treatment for hypertension, CNS: dizziness, fatigue, Monitor BP and pulse
meals HF, or left ventricular weakness, anxiety, depression, frequently; monitor
dysfunction after myocardial drowsiness, insomnia, memory I&O ratios as well as
4
infarction. Decreases heart rate loss, mental status changes, daily weights; assess for
and BP, improves CO, slows nervousness, nightmares HTN; check BUN,
the progression of HF, and EENT: blurred vision, dry eyes, serum lipoprotein,
decreases the risk of death nasal stuffiness potassium, triglyceride,
(Vallerand, Sanoski, & Deglin, Resp: bronchospasm, wheezing and uric acid levels
2017). CV: bradycardia, HF, pulmonary (Vallerand, Sanoski, &
edema Deglin, 2017).
GI: diarrhea, constipation,
nausea
GU: erectile dysfunction,
decreased libido
Derm: steven-johnson’s
syndrome, toxic epidermal
necrolysis, itching, rashes,
urticaria
Endo: hyperglycemia,
hypoglycemia
MS: arthralgia, back pain
Neuro: paresthesia
2017)
Digoxin 125mcg PO Daily Treatment for heart failure, CNS: fatigue, headache, Monitor apical pulse for
atrial fibrillation and atrial weakness 1 full minute before
flutter, and paroxysmal atrial EENT: blurred vision, yellow or administering; monitor
tachycardia. Increases cardiac green vision BP periodically;
output and slows heart rate CV: arrhythmias, bradycardia, monitor ECG, withhold
(Vallerand, Sanoski, & Deglin, ECG changes, AV block, SA med if pulse is <60 bpm
2017). block and notify HCP
GI: anorexia, nausea, vomiting, (Vallerand, Sanoski, &
diarrhea Deglin, 2017).
Hemat: thrombocytopenia
Metab: electrolyte imbalances
2017).
Doxycycline 100mg PO BID Treatment of various infections, CNS: benign intracranial Assess for infection
inhalation anthrax, gonorrhea hypertension, headache before and during drug
and syphilis, prevention of GI: pseudomembranous colitis, therapy, obtain
exacerbations of chronic diarrhea, nausea, vomiting, specimens for C&S
bronchitis, and treatment of esophagitis, hepatotoxicity, before starting therapy,
inflammatory lesions associated pancreatitis monitor bowel function,
5
with rosacea. Bacteriostatic Derm: drug rash with assess for rash
action against susceptible eosinophilia and systemic periodically throughout
bacteria (Vallerand, Sanoski, & symptoms, erythema therapy, and monitor
Deglin, 2017). multiforme, stevens-johnson renal and hepatic
syndrome, toxic epidermal functions as well as
necrolysis, photosensitivity, rash CBC throughout
Hemat: blood dyscrasias therapy (Vallerand,
(Vallerand, Sanoski, & Deglin, Sanoski, & Deglin,
2017). 2017).
Furosemide 40mg IV Push Q12h Treatment for edema due to CNS: blurred vision, dizziness, Assess fluid status,
HF, hepatic impairment or renal HA, vertigo monitor daily weights
disease, and to treat HTN. EENT: hearing losstinnitus and I&O ratios; monitor
Causes diuresis and subsequent CV: hypotension BP and pulse before
mobilization of excess fluid and GI: anorexia, constipation, and during therapy;
decreases BP (Vallerand, diarrhea, dry mouth, dyspepsia, assess patient for
Sanoski, & Deglin, 2017). increased liver enzymes, nausea, anorexia, N/V, muscle
pancreatitis, vomiting cramps, paresthesia,
GU: increased BUN, excessive and confusion; assess
urination, nephrocalcinosis for hearing loss and
Derm: erythema multiforme, tinnitus; assess for
steven-johnson syndrome, toxic allergies to
epidermal necrolysis, pruritus sulfonamides; assess
Endo: hypercholesterolemia, patient for skin rash
hyperglycemia frequently, and monitor
F&E: dehydration, electrolytes, renal and
hypocalcemia, hypochloremia, hepatic functions
hypokalemia, hypomagnesemia (Vallerand, Sanoski, &
(Vallerand, Sanoski, & Deglin, Deglin, 2017).
2017).
Quaifenesin 1200mg PO BID Maintenance for coughs CNS: dizziness, headache Assess lung sounds,
associated with viral upper GI: nausea, diarrhea, stomach frequency and type of
respiratory tract infections. pain, vomiting cough, and character of
Mobilization and subsequent Derm: rash, urticaria bronchial secretions
expectoration of mucus (Vallerand, Sanoski, & Deglin, (Vallerand, Sanoski, &
(Vallerand, Sanoski, & Deglin, 2017). Deglin, 2017).
2017).
Levothyroxine 25mcg PO Daily Thyroid supplement in CNS: HA, insomnia, irritability Assess apical pulse &
hypothyroidism. Replacement CV: angina pectoris, BP. Administer on an
of or supplementation to arrhythmias, tachycardia empty stomach.
endogenous thyroid hormones GI: abdominal cramps, diarrhea, Monitor thyroid
6
to restore normal balance. vomiting function. monitor TSH
(Vallerand, Sanoski, & Deglin, Derm: sweating serum levels.
2017). Endo: hyperthyroidism, (Vallerand, Sanoski, &
menstrual irregularities Deglin, 2017).
Metab: heat intolerance, weight
loss
2017).
Losartan 25mg PO BID Management of hypertension. CNS: dizziness, fatigue, Assess BP and pulse
Lowers patients BPand headache, insomnia, weakness frequently, monitor
decreases incidence of stroke CV: chest pain, edema, frequency of
and left ventricular hypertrophy hypotension prescription refills to
(Vallerand, Sanoski, & Deglin, EENT: nasal congestion determine compliance,
2017). Endo: hypoglycemia, weight assess for signs of
gain angioedema, and
GI: diarrhea, abdominal pain, monitor renal function
dyspepsia, nausea (Vallerand, Sanoski, &
GU: impaired renal function Deglin, 2017).
F&E: hyperkalemia
MS: back pain, myalgia
2017).
Montelukast 10mg PO Daily Prevention and chronic CNS: suicidal thoughts, Assess lung sounds and
treatment of asthma. agitation, aggression, anxiety, respiratory function
Management of seasonal depression, disorientation, dream prior to and periodically
allergic rhinitis. Decreased abnormalities, fatigue, during therapy; assess
frequency and severity of acute hallucinations, HA, insomnia, allergy symptoms;
asthma attacks and decreased irritability, restlessness, tremor, monitor closely for
severity of allergic rhinitis weakness changes in behavior;
(Vallerand, Sanoski, & Deglin, EENT: nosebleed assess for rash
2017). Resp: cough, rhinorrhea throughout treatment;
GI: abdominal pain, diarrhea, monitor liver enzymes
dyspepsia, increased liver (Vallerand, Sanoski, &
enzymes Deglin, 2017).
Derm: rash, Stevens-Jonson
Syndrome
2017).
Pantoprazole 40mg PO Daily Erosive esophagitis associated CNS: headache Assess patient for
with GERD. Maintenence of GI: CDAD, abdominal pain, epigastric or abdominal
7
healing of erosive esophagitis. diarrhea, eructation, flatulence pain as well as for frank
Diminishes accumulation of Endo: hyperglycemia or occult blood in stool,
acid in the gastric lumen, F&E: hypomagnesemia assess liver function
lessening acid reflux. Heals GU: acute interstitial nephritis tests, and monitor
duodenal ulcers and esophagitis Hemat: vitamin B12 deficiency bowel function
(Vallerand, Sanoski, & Deglin, MS: bone fracture (Vallerand, Sanoski, &
2017). (Vallerand, Sanoski, & Deglin, Deglin, 2017).
2017).
Prednisone 40mg PO Daily Used systemically and locally CNS: depression, euphoria, HA, Assess involved
in a wide variety of chronic increase intracranial pressure, systems before and
diseases including: psychoses, restlessness during drug therapy,
inflammatory, allergic, EENT: cataracts, increased assessing patients for
hematologic, neoplastic, and intraocular pressure signs of adrenal
autoimmune disorders. CV: hypertension insufficiency, monitor
Suppression of inflammatory GI: peptic ulceration, anorexia, I&O ratios and daily
and modification of the normal nausea, vomiting weights, monitor serum
immune response (Vallerand, Derm: acne, decreased wound electrolytes and glucose
Sanoski, & Deglin, 2017). healing, ecchymoses, fragility, (Vallerand, Sanoski, &
hirsutism, petechiae Deglin, 2017).
Endo: adrenal suppression,
hyperglycemia
F&E: fluid retention,
hypokalemia
Hemat: thromboembolism
Metab: weight gain, weight loss
2017).
Spironolactone 12.5mg PO Daily Management of primary CNS: dizziness, clumsiness, Monitor I&O and daily
hyperaldosteronism; sedation weights; evaluate BP
management of edema related CV: arrhythmias before administering;
to HF, cirrhosis, and nephrotic GI: GI irritation monitor response of
syndrome; management of GU: erectile dysfunction, signs and symptoms of
essential HTN; and treatment of dysuria hypokalemia; assess
hypokalemia. Increases survival Endo: amenorrhea, patient for skin rash
in patients with severe HF. gynecomastia, breast tenderness, frequently throughout
Weak diuretic and deepening voice, increased hair therapy; evaluate serum
antihypertensive response when growth, and sexual dysfunction potassium levels prior
compared with other diuretics. F&E: hyperkalemia, to and during therapy;
Conservation of potassium hyponatremia monitor BUN, serum
(Vallerand, Sanoski, & Deglin, Hemat: agranulocytosis, creatinine, and
8
2017). thrombocytopenia electrolytes prior to and
Derm: DRESS, alopecia, periodically during
pruritus therapy (Vallerand,
MS: muscle cramps Sanoski, & Deglin,
(Vallerand, Sanoski, & Deglin, 2017).
2017).
Warfarin 5mg PO Daily Prophylaxis and treatment of GI: cramps, nausea Assess for signs of
venous thrombosis, pulmonary Derm: dermal necrosis bleeding and
embolism, and atrial Hemat: bleeding hemorrhage, asses for
fibrillation with embolization. Misc: fever evidence of additional
Prevention of thrombus (Vallerand, Sanoski, & Deglin, thrombosis, monitor
formation and embolization 2017). PT, INR, and other
after prosthetic valve clotting factors
replacement. Prevents frequently, monitor
thromboembolic events hepatic function and
(Vallerand, Sanoski, & Deglin, CBC (Vallerand,
2017). Sanoski, & Deglin,
2017).
Benzonatate 200mg PO TID prn Relief of nonproductive cough CNS: HA, mild dizziness, Assess frequency and
cough due to minor throat or bronchial sedation nature of cough, lung
irritation from inhaled irritants EENT: burning sensation in sounds, and amount and
or colds. Decreases cough eyes, nasal congestion type of sputum
(Vallerand, Sanoski, & Deglin, GI: constipation, GI upset, produced (Vallerand,
2017). nausea Sanoski, & Deglin,
Derm: pruritus, skin eruptions 2017).
2017).
Chlorpheniramine 5mL PO Q12h prn Relief of allergic symptoms CNS: drowsiness, dizziness Assess allergy
cough caused by histamine release and EENT: blurred vision symptoms, monitor BP
management of severe allergic CV: hypertension, arrhythmias, and pulse, assess for
or hypersensitivity reactions. hypotension, palpitations adverse anticholinergic
Decreased symptoms of GI: dry mouth, constipation, effects, and assess lung
histamine excess (Vallerand, obstruction sounds (Vallerand,
Sanoski, & Deglin, 2017). GU: retention, urinary hesitancy Sanoski, & Deglin,
(Vallerand, Sanoski, & Deglin, 2017).
2017).
Insulin lispro Lower SQ QID prn Control of hyperglycemia in Endo: hypoglycemia Assess for symptoms of
resistance patients with type 1 and type 2 Local: lipodystrophy, pruritus, hypoglycemia; monitor
correctional diabetes mellitus (Vallerand, erythema, swelling body weight
dose Deglin, Sanoski, 2017). Misc: allergic reactions periodically; monitor
9
(Vallerand, Deglin, Sanoski, blood glucose
2017). (Vallerand, Sanoski, &
Deglin, 2017).
Nitroglycerin 0.4mg SL Q5min prn Management of acute angina CNS: dizziness, HA, Assess location,
chest pain pectoris, production of apprehension, restlessness, duration, and intensity
controlled hypotension during weakness of pain; monitor BP and
surgical procedures, and EENT: blurred vision pulse before
treatment of HF associated with CV: hypotension, tachycardia, administration; may
acute MI. Relief or prevention syncope cause false increased
of anginal attacks, increased GI: abdominal pain, N/V serum cholesterol levels
CO, and reduction of BP Derm: contact dermatitis (Vallerand, Sanoski, &
(Vallerand, Sanoski, & Deglin, (Vallerand, Sanoski, & Deglin, Deglin, 2017).
2017). 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 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)
Decreased cardiac output related to heart failure as evidenced by altered stroke volume.
Patient will verbalize knowledge R.E. will verbalize and 1. Teach patient to report chest 1. Chest pain may indicate R.E. acknowledged the signs
of reportable signs and acknowledge signs and pain right away. myocardial hypoxia or and symptoms of heart
symptoms. symptoms of heart failure by 2. Teach patient about injury. failure and verbalized them
the end of my shift. reportable symptoms 2. These measures let the before the end of my shift.
including palpitations, patient participate and
weakness, dizziness, and acknowledge his care.
syncope. 3. These symptoms may
3. Teach patient to report indicate cerebral hypoxia
dizziness or syncope resulting from cardiac
promptly. rhythm disturbance.
(Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,

2017). 2017).
Secondary Nursing Diagnosis:
10
Impaired gas exchange related pneumonia as evidenced by dyspnea.
Patient will maintain an R.E. will maintain a respiratory 1. Monitor vital signs and 1. Monitoring vitals will R.E. maintained a respiratory
adequate respiratory rate. rate within five breaths of his heart rhythm every four assess where the patient’s rate within five breaths of his
baseline throughout my shift. hours. RR is related to his baseline throughout the entirety
2. Elevate the head of patients baseline. of my shift.
bed to improve chest 2. Improving chest expansion
expansion. will enhance gas exchange.
3. Teach patient relaxation 3. Implementing relaxation
techniques. techniques will reduce
tissue oxygen demand.
(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.”
11
References
Harding, M., Roberts, D., Reinisch, C., Hagler, D., & Kwong, J. (2020). Medical-surgical nursing: assessment and management of
clinical problems. St. Louis, MO: Elsevier, Inc.
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.
12

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Medsurg Careplan 3

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Med-Surg Care Plan

Student: Samantha Wiederkehr Date: 02-24-20

Course: 320CC Instructor: Professor McNiff

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

© 2019. Grand Canyon University. All Rights Reserved.

(Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor,

clinical problems. St. Louis, MO: Elsevier, Inc.

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