Med Surg- Care Plan

Student: Chelsey Burbach Date: 03/12/2020

Course: NSG- 320CC Instructor: Professor Kelly Schaefer

Clinical Site: Mountain Vista Client Identifier: P.B Age: 52

Reason for Admission: Mr. P.B was admitted on 03/02/20. The client presented to the ED with shallow breathing, diarrhea, cough, and
weakness.

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

Esophageal Cancer is a result of cellular DNA being damaged. It is
linked to the squamous epithelium being inflamed and leading to
dysplasia and in situ malignant transformation. The distal esophagus is the
area that is mostly affected by adenocarcinoma and has a distinct
relationship to GERD.
Client presented with shortness of breath, coughing, and diarrhea.
When first arriving at the ED the patient was extremely weak. He
was barely able to lift his own head up. His wife stated that he had
uncontrollable diarrhea and was also having difficulty catching his
breath that was accompanied by a deep cough.

Risk factors for esophageal cancer include age (45-70), gender, race,
tobacco, alcohol, GERD, obesity, HPV, and Achalasia.
(Jain & Dhingra, 2017)
Typical clinical manifestation that are present with esophageal
cancer are dysphagia, weight loss, chest pain/pressure, worsening
heartburn, hoarseness, and coughing. Vomiting may also be present
along with choking on food frequently.
(Jain & Dhingra, 2017)

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 Assessment Data
Subjective Data: Client presents with nausea, shortness of breath, and throat pain.
VS: Labs: Diagnostics:
0800 WBC (5 – 10) All imaging was performed on 03/02/20
T : 37.0 0.3 – low CT Abd/Pelvis with and without contrast- Left pleural
effusion and metastasis to liver
BP: 93/63 RBC (2.8 – 5.7)
CT Angio- positive for bilateral pulmonary effusion
HR: 85 3.1
RR: 18 Hgb (12.0 – 16.0)
O2 Sat: 97% RA 8.0 – low
Pain: 3/10 (throat) Hct (37 – 52)
1200 24.5 – low
T : 37.4
Na (136 – 145)
BP: 97/55
129 – low
HR: 89
Plt (150 – 400)
RR: 18
97 – low
O2 Sat: 99% RA
Bun (10 – 20)
Pain: 4/10 (throat)
8 – low
Cr (0.5 – 1.2)
0.30 – low
Chl (98 – 106)
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101
Glucose (74 – 106)
111 – high
Ca (8.6 – 10.2)
7.50 – low
Mag (1.5 – 2.5)
1.7
PTT (25 – 35)
31.9
TSH (0.4 – 4.0)
1.270
Blood Cx – x2
Negative
C-Diff
Negative
Stool Cx
Negative
Urinalysis
Negative
Client had many labs that were abnormal. This is
due to the patients cancer. He has severe
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 malnutrition and has been going through
chemotherapy.

Assessment: Orders:
Past medical history: Client has a complex history. He has stage 4 Contact Precautions (C-diff)
esophageal cancer, severe malnutrition, hyponatremia, pancytopenia,
ED Sepsis Alert
diarrhea and atrial tachycardia.
Tube feeding
Height & Weight: 72” – 58kg
SCD
Neuro: A & O x 4. PERRLA. Client is very oriented and understanding
of his condition. He is smiling and laughing. He shows no signs of I & O Monitoring
anger or anxiety.
Cardiac monitor – A- tach
Respiratory: Lung sounds in anterior chest were diminished bilateral
throughout. Good respiratory effort, non-labored. Braden Assessment

Cardiovascular/Vascular: No edema noted. Capillary refill < 3 Morse Fall Risk Assessment
seconds. Radial pulses palpable, 3+. Heart sounds S1 and S2 present. Maintain and improve skin integrity
No S3 or S4 sounds noted. ECG monitoring showed episodes of atrial
tachycardia and atrial flutter.
GI: Abdomen is flat, non-tender, and non-distended. Feeding tube
placed in left upper quadrant. Bowel sounds were noted in all four
quadrants.
GU: Client was able to urinate on his own without a problem in his
bedside urinal. Clear, yellow, no odor, or blood noted.
Skin: Color is consistent with ethnicity. Warm, dry and intact. No
abnormalities noted.
Muscle Skeletal: Client does not ambulate independently. He is weak
in all four quadrants. He can ambulate with PT.

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Diet: Client does have feeding tube placed, but feedings were
discontinued due to diarrhea. Patient diet was changed to a cardiac diet
and to eat food as tolerated.
ADL/ Hygiene: Oral care, peri care, and skin care are all performed by
self with no assistance.
IV Access: 20G peripheral IV placed RFA. It is patent, dressing is dry
and intact. No redness or swelling at IV site. Placed on 3/10/20. He also
has a right subclavian port with one tube for chemotherapy.

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 Medications
ALLERGIES: Tape- rash

(Vallerand, Sanoski, & Quiring, 2019)

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Acetaminophen 650mg PO Two q6h prn Mild pain/prescribed for Hepatotoxicity, rash, Assess for rash during
pain neutropenia therapy. Assess liver
function test. Assess
pain level. Advise
client to notify nurse
if any nausea or rash
occur.

Cefepime 1000mg IV PB Q8h Treatment of infections of Seizures, diarrhea, Before initiating

uncomplicated skin and skin anaphylaxis, fever, c-diff therapy obtain
structure infections/ patient history. Observe for
was prescribed for infection s/s of anaphylaxis,
assess for infection
and beginning and
throughout therapy.
Flagyl 500mg IV PB Q8h Treatment of intra- Seizures, rash, phlebitis, Assess for infection at
abdominal infections/ patient glossitis, vomiting beginning and
was prescribed for infection throughout therapy.
prevention Assess for rash
periodically. Monitor
I&O.
Heparin 25000U IVDrip 250mL Prevention of Dizziness, headache, Assess for any signs of
VTE/prescribed to patient bleeding, anemia, fever bleeding. Monitor for
for bilateral PE hypersensitive
reactions. Advise
client to notify nurse
of any bleeding.
Percocet 5/325mg PO Q4h prn pain Moderate to severe pain/ Confusion, sedation, Assess location and
7 – 10 prescribed for client if he has constipation, respiratory intensity of pain.
pain depression Asses BP, pulse, and
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 respirations. Advise
client to notify nurse
if any side effects
occur.
Vancomycin 1250mg IVP Q8h Treatment of potential life- Superinfection, ototoxicity, Assess patient for
threatening infections or hypotension, back and neck infection at the
treatment of diarrhea due to pain beginning of and
Clostridium difficile throughout therapy.
Obtain specimen
cultures and
sensitivity prior to
initiating therapy.
Monitor IV site
closely. Monitor
intake and output.
Observe for s/s of
anaphylaxis.
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) (Phelps, Ralph, & Taylor, 2017)
Death anxiety related to fear of dying process as evidence by patient’s expressions of feelings related to death
Rationale: This was chosen as priority diagnosis due to the patient feeling very overwhelmed that he is not going to be here for much longer. He
was crying and calling family to come be with him, because he was afraid that he wasn’t going to be here soon due to the new diagnosis of
metastasis and also the pulmonary embolisms.
1. Client will identify comfort 1. Provide comfort measures 1. Some clients prefer not to be 1. The goal for the client was
- Client will be able to express measure that enhance feelings according to the patients bothered, so setting comfort met by the client choosing
feelings of comfort and of well-being before discharge. preferences. measures allows the clients comfort measures that
peacefulness. feelings to be expressed. enhance his well-being.
2. Client will communicate 2. Help clients family members to
important thoughts and identify, discuss and help resolve 2. Clients need the support of 2. The goal for the client was
feelings to his family before and issues related to client dying. their family members during this met by client engaging in
discharge. time. conversation with his family

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Secondary Nursing Diagnosis: (Phelps, Ralph, & Taylor, 2017)
Chronic pain related to self-report of pain using the pain scale as evidence by patient’s description of physical pain
- Client will help develop pain
management program that
includes rest schedule, activity
schedule, and medication
regimen.
3. Client will use available
support systems to help him
cope with death before
discharge.
1. Client will identify
characteristics of pain and pain
behaviors within one to two
days after admission.
2. Client will state the
importance of self-care
behavior or activities within
one to two days after
admission.
3. Client will be able to state
relationship of increasing pain
within one to two days after
admission.
3. Help client cope by actively
listening and communicating his
thoughts and feelings.
1. Assess clients physical
symptoms of pain. Administer
pain medications as they are
prescribed, and monitor the
effectiveness of medication.
2. Encourage self-care activities
and develop a schedule.
3. Use behavior modifications
that stop the conversation from
pain talk. Use contingency
rewards when client decreases
pain behavior or talk.
3. Clients who are dying need
the opportunity to express their
feelings.
1. Calculating the clients pain
with time of day, activities, and
visits can help modify tasks and
medication schedule.
2. Helps the client gain a sense
of control and will reduce the
dependence on caregivers, or
family.
3. Reducing pain talk can help
the client refocus on other,
more important matters.
and caregivers.
3. The goal for the client was
met by client using the
available support system to
cope with the dying process.
1. The goal for the client was
met by client maintaining pain
management programs that
include activity and rest
schedules, and medication
regimens.
2. The goal for the client was
met by him stating the
importance of self-care
activities.
3. The goal for the client was
met by client describing
physical pain, pain relief, and
feelings about his pain.

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:
Jain, S., & Dhingra, S. (2017). Pathology of esophageal cancer and Barrett's esophagus. Annals of cardiothoracic surgery, 6(2), 99–

109. https://doi.org/10.21037/acs.2017.03.06

Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Sparks & Taylors nursing diagnosis reference manual. Philadelphia: Wolters

Kluwer Health.NAND

Vallerand, A. H., Sanoski, C. A., & Quiring, C. (2019). Daviss drug guide for nurses. Philadelphia, PA: F.A. Davis Company.