Care Plan

Student: Caitlyn Summers Date: 3/2/20

Course: NSG-320CC Instructor: Professor Geeen

Clincial Site: Banner Del Webb Client Identifier: J.G. Age: 51

Reason for Admission: J.G. came to the ED after becoming winded waling to the restroom. She was experiencing shortness of breath, for the
past week. She also reported having a productive cough, with mucus, but no fever or chills. J.G. also mentioned that she does have asthma and
ran out of her medication, Advair, that she typically takes.

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

Asthma Exacerbation –
Asthma exacerbations, or asthma attacks, cause the airways to get J.G.'s current clinical manifestations that she is experiencing
inflammed, swell, and produce extra mucus narrowing the airways. Those include: getting winded while walking, non-productive cough, and
who are experiencing an attack typically cough, wheeze and have a slight wheeze.
difficulty breathing. Asthma attacks can vary from mild, moderate to
severe and if not treated could be life-threatening. Triggers may include
pollen, pets, mold, upper respiratory infections, tobaccor smoke, inhaling Other common clinical manifestations include chest tightness, chest
cold, dry air, GERD, and stress. Those who are at risk include; a history pain, productive cough, wheezing, and low peak expiratory flow
of asthma attacks, if you use two quick-actinginhalers a month, previous (PEF) readings (Asthma attack, 2019).
visits to the ED due to an asthma attack and chronic health conditions like
chronic lung disease or cardiovascular disease (Asthma attack, 2019).

Assessment Data
Subjective Data: “I just feel like I am carrying extra weight when I try to walk around the floor.”

© 2019. Grand Canyon University. All Rights Reserved.

VS: Taken at 0730 Labs: 2/29/20 Diagnostics:
T : 98.2 F CBC – Chest Single View Frontal –
BP: 147/81 WBC: 15.1 K/MM3 H (N: 4-11) The x-ray showed unremarkable findings.
HR: 81 This lab is abnormal due to obesity, or specific
RR: 18 medications she mights be on, specifically beta
agonists like albuterol.
O2 Sat: 96% on RA
RBC: 4.90 M/MM3
Pain: 0/10
HBG: 12.8 g/dL
Taken at 1445
HCT: 40.6 %
T: 98.5 F
MCV: 83fL
BP: 138/82
MCH: 26.1 pgL H (N: 27-34)
HR: 80
This lab is abnormal due to a low amount of iron
RR: 16
or other vitamins like B12 and folate.
O2 Sat: 96% on RA
MCHC: 31.5 g/dL
Pain: 0/10
Platelet: 383 K/MM3
CHEM GEN –
Gluscose: 142 mg/dL H (N: 70-106)
This lab is abnormal due to the steroid
medication she is on, methylpresidone which can
increase blood glucose levels.
BUN: 22mg/dL
Creatinine: 0.95 mg/dL

2
 BUN/Creatinine ratio: 23
Sodium: 137mmol/L
Potassium: 4.0mmol/L
Chloride: 99mmol/L
CO2: 24mmol/L
Calcium: 8.9mg/dL

Assessment: Orders:
Pt History: P.T has a past medical history of asthma, anxiety and HTN Nutrition Orders:
Neuro: LOC alert and orientated x4 - Regular Diet
Speech clear Medical Imaging:
Pupils are equal, round, reactive to light bilaterally, Pupil size is - Chest X-Ray
approximately 4mm bilaterally
Therapies:
Eyes open spontaneously
- RSP Lung expansion therapy Q4H while awake
Patient is cooperative - RSP airway clearance therapy Q2H PRN cough & congestion
- RSP Chronic BIPAP
Resp: Patient is on RA
Lab:
O2 sat. is 94%, RR are 18
- CBC
Lung sounds show are clear on both sides in the upper lobes and
- Blood Culture
diminished in both lower lobes
3
 Breathing is unlabored Nursing Orders:
Chest is symmetrical - Education on VTE
- Line maintenance
Non-productive cough with no sputum
Activity:
Cardiovascular: S1 and S2 heart sounds noted, no S3 or S4
- Ambulate with assistance
HR is 76, BP is 165/85
Regular rate/rhythm
Radial and pedal pulses are palpable bilaterally approx. 2+
No lower body edema noted bilaterally
No upper body edema noted bilaterally
GI: Abdomen is obese and soft, no tenderness noted
Hypoactive BS
Last bowel movement was 2/24
Brown color and normal consistency
Regular diet
Ate 100% of breakfast and lunch
GU: Voids without difficulty, pain or burning
Urine is yellow and clear
Skin: Warm, dry and intact
Skin is appropriate for ethnicity
No wounds present

4
Musculoskeletal: Ambulates independently
Equal strength in upper and lower extremities with and without
resistance
Mild fall precautions
Hygiene: Received shower on 2/28
Patient does their own oral and pericare daily
Linens last changed on 2/28
Monitoring lines/IV:
Midline IV in right upper arm size 18g
Pain: Patient reports no pain
0/10 on pain scale

5
6
 Medications
ALLERGIES: Hydrocodone (Vomiting), Penicillin (unknown), Aerobid (SOB), Atrovent (SOB), budesonide (Anxiety states), Biaxin (Anxiety
states)

Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing

Effect Considerations
Albuterol-ipratropium 3mL Nebulizer Q4H Maintenance therapy of Dizziness, headache, -Assess respiratory
(CuoNeb) reversible airway nervousness, blurred status (rate, breath
obstructions due to COPD vision, bronchospasm, sounds, degree of
(Vallerand, Sanoski, & cough, hypotension, dyspnea, pulse)
Deglin, 2017). palpitations, GI irritation, before
nausea, ash, allergic administration and
reactions (Vallerand, at peak of
Sanoski, & Deglin, 2017). medication
-Instruct patient in
proper use of
inhaler, nebulizer,
or nasal spray and
to take medication
as directed
-Advise patients to
rinse their mouth
after using inhaler,
perform good oral
hygiene, and
sugarless gum or
candy may
minimize dry
mouth
(Vallerand,
Sanoski, & Deglin,
7

Methylprednisolone 60mg/0.96m IV Push Q6H Used for treatment of Depression, euphoria,
L systemic and local headache, personality
inflammatory response to changes, psychoses,
chronic disease restlessness, cataracts,
(Vallerand, Sanoski, & increased intraocular
Deglin, 2017). pressure, hypertension,
Peptic ulceration, anorexia,
nausea, vomiting, acne,
prolonged wound healing,
ecchymoses, fragility,
hirsutism, petechiae,
adrenal suppression,
hyperglycemia, fluid
retention (long-term high
doses), hypokalemia,
hypokalemic alkalosis,
Thromboembolism,
thrombophlebitis, weight
gain, weight loss, muscle
wasting, osteoporosis,
avascular necrosis of
joints, muscle pain
(Vallerand, Sanoski, &
Deglin, 2017).
Guaifensin (Mucinex) 600mg/1 PO BID Treatment for cough Dizziness, headache,
tab associated with viral nausea, diarrhea, stomach
URTI (Vallerand, pain, vomiting, rash,
Sanoski, & Deglin, 2017). urticaria (Vallerand,
Sanoski, & Deglin, 2017).
2017).
-Caution patient to
avoid vaccines
-Teach them to
avoid people with
contagious illnesses
-Warm patient to
report signs of
abdominal pain,
black tarry stool,
unusual swelling,
weight gain or
bruising
(Vallerand,
Sanoski, & Deglin,
2017).
-Assess lung
sounds, frequency
and type of cough,
and character of
bronchial secretions
periodically during
therapy. Maintain
8
fluid intake of 1500
– 2000 mL/day to
decrease viscosity
of secretions.
-Instruct patients to
cough effectively.
Patients should sit
upright and take
several deep
breaths before
attempting to
cough.
-Inform patients
that this drug may
occasionally cause
dizziness. Avoid
driving or other
activities requiring
alertness until
response to drug is
known.
-Advise patients to
limit talking, stop
smoking, maintain
moisture in
environmental air,
and take some
sugarless gum or
hard candy to help
alleviate the
discomfort caused
by a chronic
nonproductive
cough
9
 (Vallerand,
Sanoski, & Deglin,
2017).
Diphenhydramine 50mg/1 cap PO Q bedtime Mild nighttime sedation Drowsiness, dizziness, -Assess sleep
PRN (Vallerand, Sanoski, & headache, paradoxical patterns.
insomnia Deglin, 2017).. excitation (increased in -Administer with
children), blurred vision, meals or milk to
tinnitus, hypotension, minimize GI
palpitations, anorexia, dry irritation. Capsules
mouth, constipation, may be emptied
nausea, dysuria, frequency, and contents taken
urinary retention, with water or food.
photosensitivity, chest -May cause
tightness, thickened sedation and
bronchial secretions, confusion due to
wheezing (Vallerand, increased
Sanoski, & Deglin, 2017). sensitivity to anti-
cholinergic effects.
Monitor carefully,
assess for
confusion,
delirium, other anti-
cholinergic side
effects and fall risk.
Institute measures
to prevent falls
(Vallerand,
Sanoski, & Deglin,
2017).
Azithromycin 500mg/2 PO Daily Treatment of LRTI, Dizziness, seizures, -Administer 1hr
tab specifically pneumonia drowsiness, fatigue, before or 2hr after
(Vallerand, Sanoski, & headache. Torsade’s de meals.
Deglin, 2017). pointes, chest pain, -Instruct patients to

10
hypotension, palpitations, take medication as
QT interval prolongation, directed and to
hepatotoxicity, finish the drug
pseudomembranous colitis, completely, even if
abdominal pain, diarrhea, they are feeling
nausea, cholestatic better. Take missed
jaundice, increase liver doses as soon as
enzymes, dyspepsia, possible unless
flatulence, melena, oral almost time for
candidiasis, pyloric next dose; do not
stenosis, nephritis, double doses
vaginitis, anemia, -Advise patients to
leukopenia, use sunscreen and
thrombocytopenia, Steven protective clothing
Johnsons syndrome, Toxic to prevent
epidermal necrolysis, photosensitivity
photosensitivity, rash, reactions.
ototoxicity, hyperkalemia, -Assess patient for
angioedema (Vallerand, skin rash frequently
Sanoski, & Deglin, 2017). during therapy.
Discontinue
azithromycin at
first sign of rash;
may be life-
threatening.
-Advise patients to
report symptoms of
chest pain,
palpitations,
yellowing of skin
or eyes, or signs of
superinfection
(black, furry
overgrowth on the
11
 tongue; vaginal
itching or
discharge; loose or
foul-smelling
stools) or rash.
- Warn health care
provider if fever
and diarrhea appear
(Vallerand,
Sanoski, & Deglin,
2017).
Albuterol 2.5 Nebulized Q2H PRN Bronchodilator, to control Nervousness, restlessness, -Assess lung
mg/3mL wheeze & and prevent reversible tremor, headache, sounds, pulse, and
SOB airway obstruction caused paradoxical BP before
by COPD (Vallerand, bronchospasms (excessive administration and
Sanoski, & Deglin, 2017). use of inhalers), chest pain, during peak of
palpitations, angina, medication. Note
arrhythmias, hypertension. amount, color, and
nausea, vomiting, character of sputum
hyperglycemia, produced
hypokalemia, tremor -Monitor
(Vallerand, Sanoski, & pulmonary function
Deglin, 2017). tests before
initiating therapy
and periodically
during therapy.
-Observe for
paradoxical
bronchospasm
(wheezing)
-Advise patients to
use albuterol first if
using other
inhalation
12
 medications and
allow 5 min to
elapse before
administering other
inhalant
medications unless
otherwise directed
-Advise patients to
rinse mouth with
water after each
inhalation dose to
minimize dry
mouth and clean
the mouthpiece
with water at least
once a week.
(Vallerand,
Sanoski, & Deglin,
2017).
Enoxaparin (Levonax) 40mg/0.4 SubQ QBedtime Anticoagulant for Dizziness, headache, -Assess for signs of
mL prevention of venous insomnia, edema, bleeding and
thromboembolism (VTE) constipation, increase liver hemorrhage
and deep vein thrombosis enzymes, nausea, -Assess patient for
(DVT) (Vallerand, vomiting, urinary evidence of
Sanoski, & Deglin, 2017). retention, alopecia, additional or
ecchymoses, pruritus, rash, increased
urticaria, hyperkalemia, thrombosis.
bleeding, anemia, Symptoms depend
eosinophilia, on area of
thrombocytopenia, involvement
erythema at injection site, - Monitor CBC,
hematoma, irritation, pain, platelet count, and
osteoporosis, fever stools for occult
(Vallerand, Sanoski, & blood periodically
13
 Deglin, 2017). during therapy
(Vallerand,
Sanoski, & Deglin,
2017).
Benzonatate 100mg/1 PO TID Indications CNS: headache, mild - Assess frequency
Cap Relief of nonproductive dizziness, sedation. EENT: and nature of
cough due to minor throat burning sensation in eyes, cough, lung sounds,
or bronchial irritation nasal and amount and
from inhaled congestion. GI: type of sputum
irritants or colds. constipation, GI upset, produced.
Therapeutic Effects: nausea. Derm: pruritus, -Unless
Decrease in cough skin eruptions. contraindicated,
(Vallerand, Sanoski, & Misc: chest numbness, maintain fluid
Deglin, 2017). chilly sensation, intake of 1500–
hypersensitivity reactions 2000 mL to
(Vallerand, Sanoski, & decrease viscosity
Deglin, 2017). of bronchial
secretions
(Vallerand,
Sanoski, & Deglin,
2017).

Montelukast 10mg/1 tab PO Daily Prevention and chronic Suicidal thoughts, -Assess lung
treatment of asthma. agitation, aggression, sounds and
Management of seasonal anxiety, depression, respiratory function
allergic rhinitis. disorientation, dream prior to and
Prevention of exercise- abnormalities, fatigue, periodically during
induced hallucinations, headache, therapy.
bronchoconstriction in insomnia, irritability, -Assess allergy
patients 6 yr and older. restlessness, tremor, symptoms.
Decreased frequency and weakness (Vallerand, Monitor for
severity of acute asthma Sanoski, & Deglin, 2017). changes in behavior
14
 attacks. De- creased
severity of allergic
rhinitis. Decreased attacks
of exercise-induced
bronchoconstriction.
(Vallerand, Deglin,
Sanoski, 2017)
Budesonide 0.5mg/2mL Nebulizer BID Maintenance treatment
and prophylactic therapy
of asthma.
Decreases
frequency/severity of
asthma attacks. Improves
asthma symptoms
(Vallerand, Deglin,
Sanoski, 2017).
indicating
depression.
(Vallerand,
Sanoski, & Deglin,
2017).
Headache, rash, otitis -Monitor
media, epistaxis, respiratory status
pharyngitis, rhinitis, and lung sounds.
sinusitis, bronchospasm, Assess pulmonary
cough, abdominal pain, function tests
diarrhea, dyspepsia, periodically during
gastroenteritis, nausea, and for several
vomiting (Vallerand, months following a
Deglin, Sanoski, 2017). transfer from
systemic to
inhalation
corticosteroids
 -Assess patients
changing from
systemic
corticosteroids to
inhalation
corticosteroids for
signs of adrenal
insufficiency
(anorexia, nausea,
weakness, fatigue,
hypotension,
hypoglycemia)
during initial
therapy and periods
15

Dextromethorphan
Goal
Client or family focused.
Priority Nursing Diagnosis: Activity Intolerance related to fatigue as evidence by the need to stop to breath when walking
small distances around the unit.
Rationale: The patient has reported becoming short of breath when ambulating around the unit and when doing daily activites like getting up to
go to the restroom.
of stress
(Vallerand, Deglin,
Sanoski, 2017).
5mL PO Q4H PRN Cough suppressant that high dose — dizziness, -Instruct patient to
cough affects the cough center in sedation., nausea not drink any fluids
the medulla (Vallerand, (Vallerand, Sanoski, & immediately after
Sanoski, & Deglin, 2017). Deglin, 2017). administering so
that the medication
. does not get diluted
-Advise patient to
avoid irritants, like
smoking, or dust
-Educate the patient
that they may feel
slightly dizzy, and
to sit upright and
take several deep
breaths before
trying to cough
(Vallerand,
Sanoski, & Deglin,
2017).
Nursing Diagnoses and Plan of Care
Expected Outcome Intervention(s) Rationale Evaluation
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.
16
The patient will report no The client will be able to 1. Assess the presence 1. Provides 1. Partly met. The
episodes of dyspnea during perform daily activities of weakness and information about patient showed
activty. without showing signs of fatigue caused by energy reserves as mild signs of
difficulty breathing for airway problem. dyspnea and work fatigue when
two days (Phelps, Ralph, 2. Encourage breathing of breathing over a ambulating.
& Taylor, 2017). exercises and period of time 2. Met. The patient
controlled breathing wears out these was taught
and relaxation. reserves exericses that
3. Reinforce activity or 2. This will help to will control
exercise limitations prevent attacks breathing and
if these trigger before it begins and was able to
attack; advise increases perform teach
physician approved ventilation. back
activities, including 3. This provides 3. Met. The patient
aerobics, walking preventative identified what
and swimming. measures to offset could potentially
possible attack. be triggerign her
asthma attacks
and is going to
incorporate
activites that will
not trigger an
(Phelps, Ralph, & Taylor, (Phelps, Ralph, & Taylor, attack
2017). 2017). (Phelps, Ralph, &
Taylor, 2017).
Secondary Nursing Diagnosis: Deficient knowledge related to long-term medical management of disease as evidence by ineffective self care.
Rationale: The patient was not taking her medications because she ran out and has visited the ED several times in the past couple of months
with the same situation of asthma exacerbation.
The patient will Patient will verbalize 1. Assess client’s 1. Knowledge of 1. Met. The client
understand the knowledge of the knowledge of how to handle explained her
importance of disease and its care for status care can save knowledge of
maintaining her management and asthmaticus time what to do when
17
treatment and be able community resource 2. Educate the 2. A written copy she is starting to
to identify resources available to help the client about the of the treatment experience
available client in coping with warning signs plan is needed status
chronic disease (Phelps, and symptoms for the client to asthmaticus.
Ralph, & Taylor, 2017). of an asthma reinforce 2. Met. The client
attack and the information that was educated on
importance of wa alread the warning
early treatment taught. Early signs and
of an impending treatment within symptoms of an
attac. Provide a 6 hours of an asthma attack
written copy of attack may and the
exacerbation lessen the importance of
management chance of recogninsing it
and have the hospitalization early on. A
patient teach 3. Enviromental paper was
back. trigger control provided for the
3. Instruct the can lessen the client to refer
client how to frequency of back to.
avoid asthma asthma attacks 3. Met. The client
triggers, like and improve the was imformed
smoke, exercise, client’s quality of potential
air pollution, of life triggers and was
and allergens (Phelps, Ralph, & able to identify
(Phelps, Ralph, & Taylor, 2017). some of hers
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 outcom

18
 Reference

Asthma attack. (2019, August 2). Retrieved from https://www.mayoclinic.org/diseases-conditions/asthma-attack/symptoms-

causes/syc-20354268

19
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.

20