Care Plan

Student: Ashlee Ceraulo Date: 2/26/2020

Course: NSG 320CC Instructor: Professor Walton

Clincial Site: Banner Boswell Client Identifier: L.F. Age: 79

Reason for Admission:

L.F. was admitted for scheduled aortic valve replacement (AVR) which resluted in a surgical error of them nicking the lung, needing follow up
surgery for pleural fluid build up of emulsified fat, termed as chylothorax. The exploratory surgery proved the lung to not be the source of the
fluid and the patient is scheduled for continuous follow up surgeries to determine and eliminate the cause.

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

L.F.’s primary medical diagnosis is chylothorax following severe L.F.s current clinical manifestations include: slight chest
aoritc valve stenosis. The pathophysiology of aortic valve stenosis discomfort due to surgical incision.
is the narrowing of the aortic valve which obstructs the blood flow Expected clinical manifestations for aortic valve stenosis
to the left ventrilce therefore not allowing sufficinet flow to the and chylothorax include: breathlessness, chest pain,
rest of the body (Aortic valve stenosis, 2018). Some risk factors pressure or tightness, plapitations, decline in activity level,
of this disorder are old age, previous heart conditions, history of or heart murmur (Aortic valve stenosis, 2018).
infections, or a history of diabetes, high cholesterol, and high
blood pressure (Aortic valve stenosis, 2018). Chylothorax is due to
disruption of the thoracic duct which results in a buildup of fluid
in the pleural cavity, and some risk factors are congenital heart
surgery, invasive surgeries, or trauma (Children's Hospital, 2014).

Assessment Data
Subjective Data: L.F. is reportng little to no pain consistantly, he says he has no cardiac concerns since the surgery, reports playing tennis
when at home and feels great. He is eager to go home and frustrated at the unknown leakage and motivated to contribute to the discovery and

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treatment.
VS: (2/26/2020, 0900) Labs: (2/26/2020, 0800) Diagnostics:
T : 37 C Glucose POC 124 mg/dL H (normal: 80-100) (2/8/2020, 1206) Vasculardiagrams and tech reports
BP: 110/65 The patients glucose could be high due to an (2/26/2020, 0700) Cardiopulmonary Rpt
infection from the surgery.
HR: 53 bpm
RR: 18 Glucose level 137 mg/dL H (normal: 80-130)

O2 Sat: 98% The patients glucose level could be high due to

the body’s response to the trauma and
VS: (2/26/2020, 1200) medications that he is on.
T : 36.9 C BUN 29 mg/dL H (normal: 7-20)
BP: 102/61 The patients BUN level could be high because of
HR: 90 bpm the increased emulsified fat needing an exit route
and the kidneys trying to work harder to
RR: 18 eliminate it.
O2 Sat: 100%
BUN/Creatinine ratio 39 H (normal: 10 to 1)
The patients BUN/Creatinine ratio could be high
due to the body’s shock or dehydration from the
several surgeries and NPO diet.
Calcium 8.4 mg/dL L (normal: 8.6-10.3)
The patients calcium could be low due to the
lack of nutrient in the diet, and loss of unknown
entirety of fluids from the patient.

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Assessment: Orders:
L.F. has a medical history of arthritis, DVT, bradycardia (only at  Aspiration risk once per shift
nighttime), hypertension, and hemochromatosis, with a family history  Incentive spirometry 8x daily
of heart attack (mom)  Raise head of bed 45-80 degrees 2x daily
Neuro: Alert and oriented x4, clear speech, PERRLA intact 3mm  Oral care 2x daily
pupils, open spontaneously, cooperative  Activity as tolerated, patient is very motivated to get up and
walk
Resp: 98% O2 Sat, clear lung sounds in all lobes, unlabored breathing,  No targeted discharge date, need to continue exploratory
no cough or sputum surgeries to discover the cause of chylothorax
Skin: Color usual for ethnicity, intact, clean, and warm, wound on right  Change drainage and meaure amount of emulsified fat daily at
lateral chest from surgical incision, no leaks, clean and dry, intact 0800
dressing and wound
Cardio: Regular rythym and rate. S1 and S2 heart sounds, both upper
and lower pulses palpable 2+, capillary refill less than two seconds
bilaterally, no upper or lower body edema, no JVD
MSK: Upper and lower extremity motor responses strong with and
without resistance, mobility x4, no fall precautions
GU: Voiding, no difficulties, urine clear, yellow, and without odor, last
output 250mL, no pain/burning
GI: Abdomen flat, symmetric, bowel sounds normoactive, last BM
2/23/2020, soft and brown formed, diet TPN, NPO
Lines and IV’s: Central line (antimicrobial coated catheter, non-
tunneled, power injectable triple internal jugular vein right), pleural
right chest tube, gastrointestinal tube (decompression large gauge ng,
nare right)

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Hygiene: Able to bathe themselves
Pain: Patient states little to no pain as a 3/10
Blood Glucose: 137, slightly high

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 Medications
ALLERGIES:

No known allergies

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect (Audet, P. R. , 1989) Considerations
(Audet, P. R. , 1989) (Audet, P. R. ,
1989)
G: Fat emulsion 250mL IV Continuous This drug is used to replace the The patient may experience a Encourage patient to
B:n/a amounts of fat the patient is headache, dizziness, nausea, notify healthcare
lacking of or losing. vomiting, or sweaing provider if any of said
effects arise, monitor
hepatic enzymes,
monitor for
hyperglycemia
G:Octreotide 500mg SubQ TID This drug is used to treat loose The patient may experience Give injections between
B:Sandostatin stools, and this patient is some abdominal pain, flatulence, meals and at bedtime to
needing this for post surgical. constipation, vomiting, diarrhea, minimize GI effects,
upper respiratory infections, or avoid multiple
flu-like symptoms injections to the same
site, give a singe dose
over 3 minutes
G:Enoxaparin 40mg SubQ Q24hrs This medication is an The patient may experience Ensure there is no pork
B:Lovenox anticoagulant and is used to some nausea, diarrhea, fever, in the diet, monitor for
treat blood clots in this patient. swelling of the hands or of the signs of bleeding, do
feet, injection site reactions not eject air bubble
prior to injection, do not
aspirate or massage site
G:Ascorbic Acid 1000mg PO Q24hrs This medication is used to treat The patient may experience May cause false
B:Vitamin C Vitamin C deficiency, and this some diarrhea, dizziness, negative results for
patient is deficient in calcium. faintness, flushing, increase need occult blood in the
to urinate, stomach cramps stool, advise patient to
take as directed, do not
abruptly withdraw
G:Salicylic Acid 325mg PO Daily This medication is a blood The patient may experience Administer after
B:Aspirin thinner used to decrease the ringing of the ears, confusion, mealsor with food to
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 chances of clotting. This patient hallucinations, rapid breathing, decrease GI upset, do
needs blood thinning due to his seizures, bloody ro tarry stools, not crush or chew, take
heart surgeries. vomit that looks like coffee with a full glass of
grounds, or long lasting fever water, monitor for signs
of bleeding
G:Insulin Lispro 2 units SubQ QID This medication is to decrease The patient may experience Assess for signs of
B:Humalog blood sugar levels, the patient hypoglycemia, heachache, hypoglycemia, use only
currently has high blood sugar. hunger, confusion, drowsiness, insulin syringes, rotate
weakness, dizziness, blurred injection sites, teach
vision, tachycardia, sweating proper administration
technique, emphasize
importance of
compliance, emphasize
not to change brands of
insulin
G:Docusate senna 1 tab PO PRN This medication is used as a The patient may experience Assess for abdominal
B:Colace stool softener, the patient need some rectal bleeding, severe distention, administer
to make a bowel movement. stomach pain, constipation with a full glass of
water preferably in the
evening, advise short
term therapy, encourage
increase bulk in the diet
G:Famotidine 20mg PO BID This medication is used to The patient may experience Assess for abdominal
B:Pepcid decrease the stomach acid in some constipation, diarrhea, pain and frank occult
the body, the patient needs this fatigue, dizziness, weakness, blood, assess elderly for
medication for the treatment of mood changes, headache, confusion, monitor
GERD. insomnia CBC, administer with
meals or immediately
afterward, open with
dry handsm
G:Ondansteron 4mg IV push Q6hr This medication is used to treat The patient may experience Assess patient for
B:Zofran nausea and vomiting, this some diarrhea, headache, fever, nausea and vomiting,
patient is on this medication for lightheadedness, dizziness, monitor ECG, assess
the decrease of these symptoms weakness, tiredness, drowsiness for extrapyramidal
after surgery. effects
G:Cefazolin 100mL IV Piggy ONCE then This medication is an antibiotic The patinet may experience Observe for signs of
B:Reflin PRN to treat infections, this patient is some injection site reactions, anaphylaxis, monitor
on this medication to decrease diarrhea, stomach pain, stomach bowel function, assess
surgical infection chances. cramps, nausea, vomiting, loss for skin rash, watch
of appetite, skin rash or itching hepatic enzymes
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 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)
Risk for infection related to unknown internal leakage as evidenced by an external collection of emulsified fat
Rationale: L.F. has undergone aortic valve replacement due to severe aortic valve stenosis which related in a complication leading to a
chylothorax of emulsified fat form an unknown internal source and has been building up for a month without discovery.
The patient will not Patient will remain free of Teach the patient the Other people can spread Met, the patients visitors
contract an infection infection, as evidenced by importance of avoiding infections or colds to were very aware and
normal vital signs and contact with individuals increase the vulnerable cautious of his condition
absence of signs and who have infections or patients chances at
symptoms of infection colds contracting an infection
throughout my shift through multiple sources Met, the patient
Encourage coughing and This helps reduce stasis of presented practice with
deep breathing as well as secretions in the lungs and the incentive spirometer
frequent position changes bronchial tree which would
and ambulation have potenially allowed (Phelps, Ralph &
pathogens to cause upper Taylor, 2017)
(Phelps, Ralph & Taylor, respiratory tract infections
2017)
(Phelps, Ralph & Taylor,

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 2017)

Secondary Nursing Diagnosis:

Powerlessness related to inability to heal as evidenced by lack of medical solution discovery
Rationale: L.F. has experienced over a month of exploratpry sugeries leading nowhere to finding a solution and is very tired of his stay in the
hospital without progress.
Feelings of hope in the The patient will express Encourage verbalization of This creates a supportive Met, he was able to talk
patient personal control of his feelings, concerns, and enviornment for the about his feelings
outlook on the situation by thoughts about his patient
the end of my shift condition

Hels the patient reexamine The patient may have the
the negative perceptions ability to understand the
about the situation positives of the situation if
presented to him
(Phelps, Ralph & Taylor,
2017) (Phelps, Ralph & Taylor,
2017)
Met, he was able to see
thankfullness that he was
still alive
(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

Audet, P. R. (1989). Daviss physicians drug guide. Philadelphia: F.A. Davis.

Aortic valve stenosis. (2018, March 9). Retrieved from https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-

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 causes/syc-20353139

Children's Hospital. (2014, August 11). Chylothorax. Retrieved from https://www.chop.edu/conditions-diseases/chylothorax

th
Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylors nursing diagnosis reference manual (10 ed.). Philadelphia, PA:

Wolters Kluwer.

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