Care Plan 1 Med Surge

NURSING
CAREPLAN TEMPLATE
Patient Data Collection Form

American Medical Academy School of Nursing
Student Name: Ania Lobeto Date: 10/29/2020 Culture/Ethnicity:

Patient Dirst and last initial: Health Insurance:Obama Religion: Christian
MS Care
Age: 67 Weight: 150 IB Language:English

Sex: Female Height: 5,6 Current Work Status:
Retired
Allergies: No known Marital Status: Widowed Occupation: N/A
allergies
Education: High School Support system: N/A
Chief Complaint:
Shortness of breath Headache
Current Diagnoses (minimum of three with citations):

Acute COPD exacerbation
Hypertension
Hyperlipidemia
Revised September 18, 2018

NURSING CAREPLAN TEMPLATE
Pathophysiology of Diagnoses (all):

The pathophysiology of severe COPD exacerbations requiring mechanical
ventilation is now well understood. Increased airways resistance, usually as a
result of worsening airway inDlammation, results in critical EFL and DH with
dramatically increased loading and functional weakness of the inspiratory
muscles.
The pathophysiology of hypertension Increased systemic vascular resistance,
increased vascular stiffness, and increased vascular responsiveness to stimuli are
central to the pathophysiology of hypertension. Morbidity and mortality
attributable to hypertension result from target organ involvement.
The pathophysiology of primary hyperlipidemia involve the idiopathic
hyperchylomicronemia in which defect in lipid metabolism leads to
hypertriglyceridemia and hyperchylomicronemia caused by a defect in lipoprotein
lipase activity or the absence of the surface apoprotein CII31
Diagnostic Procedures:
AST ALT
Medical History: Diabetes
Surgical History: Hip replacement 2005
Immunization History:
Flu Shot
Social History:She is widowed and is a retired school teacher. She lives alone but her
famil︎y visits her of︎ten︎ Smokes︎︎ ︎only 3︎ ︎-4︎ cigare︎︎ttes︎︎ per da︎y
Vital Signs Time: 0938 Respiration Rate: 28 breaths

per min
Temperature: 37 Pulse: 95 Blood Pressure: 156/92
Glucometer Reading: N/A
Safety Precautions:N/A

Limitations/Prosthetic devices: N/A
Patient Assessment Form

Neurological/ Neuromuscular
Overall Appearance:Good
LOC:Patient is alert and oriented to person, place, and time. Mood & Affect:Stability
(stable, Dixed, labile)
Mood & Affect:Stability (stable, Dixed, labile)
Sleep:Regular
Pain: N/A Location: N/A Duration: N/A Triggers: N/A Numeric Scale
0-10: 0
Paralysis/Paresis:N/A
Review of Cranial Nerves:Cranial Nerves II, III, IV, VI, VII, VIII, IX, X, XI, XII intact.
Glasgow Coma Score:15
Activity Tolerance: N/A Restrictions: N/A
ROM:Full ROM of all extremities.
Gait:Walks normal and steady
Cardiovascular
Pulses: 95 high heart rate Location: N/A
Capillary ReDill:N/A
Heart Sounds:Coarse crackles heard at the beginning of inspiration murmur is heard
while squatting or upon releaseof valsalva, standing or during valsalva strain.
Murmurs: no
Edema Score: no lower extremity edema
EKG:EKG showed sinus rhythm with a rate of 94 without RVH.
IV access (include gauge, Dluid type, and rate of Dluids):N/A

Respiratory
Oxygenation: O2 95% on 2L L/M via mask
Lung Assessment:Wheezes and rhonchi are present bilaterally without crackles. Using
auxiliary muscles to breathe.
Blood Gas: N/A
GI
Nutrition (diet):Regular
Restrictions: Sugar-sweetened beverages (soda, fruit drinks, sports drinks)
Appetite: Normal food intake
Type of Feeding: N/A Rate:N/A
Bowel Sounds: soft, positive bowel sounds
Abdominal Assessment: Inspection: Normal Palpation: Normal no pain Percussion:
Normal Auscultation: Hyperactive bowel sounds
GU
Last Bowel Movement: 10/28/2020 1030
Ostomy: N/A Output Description:Pt was incontinent of large amount of
brown bm
Site Assessment: N/A
Last Urine Void: 10/28/2020 1100 Output Description:Normal urine output
Bladder Assessment: Normal
Catheter:N/A
Type: Size:
Date of Insertion:
Integumentary
Color: N/A Temperature: 37c Turgor:Normal
Wounds: N/A
Drains: N/A
IV site: N/A
Type of Dressing:N/A
Last Dressing Change: N/A
Intake (12 Hours) Total: 2000mL Output Total (12 Hours):1000mL

Oral: 2000mL Voiding:N/A

IV:N/A Tubes/ Drains: N/A
Tubes: N/A Dressing: N/A

Nursing Diagnosis (minimum of three and Explain rationale for priority ordering
list in priority order) (include behavior and relevant stimuli)
1. 1. Exacerbations can be severe and life

Acute COPD exacerbation threatening. At the Dirst sign of symptoms, a
person should seek immediate medical
Chronic Obstructive Pulmonary Disease care. Depending on the severity and cause,
(COPD) is deDined as “a preventable and people experiencing a COPD exacerbation
treatable disease with some signiDicant will often need to stay in the hospital. COPD
extrapulmonary effects that may is terminal. People with COPD who do not
contribute to the severity in individual die from another condition will usually die
patients. Its pulmonary component is from COPD. COPD who currently smokes
characterized by airDlow limitation that tobacco has the following reductions in life
expectancy, depending on stage of COPD:
is not fully reversible.
stage 1: 0.3 years. stage 2: 2.2 years. stage 3
or 4: 5.8 years

2. 2. It's important to treat hyperglycemia,

because if left untreated, hyperglycemia can
become severe and lead to serious
Hyperlipidemia is most commonly complications requiring emergency care,
associated with high-fat diets, a such as a diabetic coma. In the long term,
sedentary lifestyle, obesity and diabetes. persistent hyperglycemia, even if not
There are also genetic causes. Familial severe, can lead to complications affecting
hypercholesterolemia, one form of your eyes, kidneys, nerves and heart. The
hyperlipidemia, is the most common brain is very resistant to protracted
neuroglycopenia, and from anecdotal
dominantly inherited genetic disorder in
accounts it would appear that you need to
humans worldwide. have at least 6 hours of exposure to very
deep hypoglycemia before you get
permanent brain damage and subsequent
death.
3. 3. Early on, you may not notice symptoms of

Hypertension High blood pressure is a high blood pressure, so you may not be too
common condition in which the long- concerned. However, in the long run high
term force of the blood against your blood pressure can kill you. Normally, your
artery walls is high enough that it may heart beats regularly, pumping blood
eventually cause health problems, such through the vessels all over your body. It
as heart disease. can lead to severe health complications and
increase the risk of heart disease, stroke,
and sometimes death. Blood pressure is the
force that a person's blood exerts against
the walls of their blood vessels. If left
untreated, a blood pressure of 180/120 or
higher results in an 80% chance of death
within one year, with an average survival
rate of ten months.


Medication Dose Route/Time Rationale for Nursing

Name (include Administration Implications
both trade/
generic name)

40 mg 1 tab PO To increase If patient

Atorvastatin daily levels of good” develops muscle
cholesterol and tenderness
(Lipitor) to lower during therapy,
triglycerides and CPK levels should
to treat the be monitored. If
symptoms of CPK levels are 10
high cholesterol times the upper
limit of normal or
myopathy occurs,
therapy should
be discontinued.
Monitor for signs
and symptoms of
immune-
mediated
necrotizing
myopathy
(IMNM)
(proximal muscle
weakness
andqserum
creatine kinase),
persisting despite
discontinuation
of statin therapy.
Perform muscle
biopsy to
diagnose; shows
necrotizing
myopathy
without
signiDicant
inDlammation.
Treat with
immunosuppress
ive agents.

750 mg 1 tab PO To treat the nausea, vomiting,

symptoms of anorexia,
Prednisone acute asthma, lethargy,
(Deltasone) arthritis, allergic confusion,
reactions, restlessness)
respiratory before and
illness, periodically
during therapy.
Monitor intake
and output ratios
and daily
weights.

50 mcg 1inhalation Used for COPD Inhaln: Once

orally twice removed from
salmeterol a day, foil overwrap,
approximat discard diskus
ely 12 when every
hours blister has been
apart. used or 6 wk
have passed,
whichever comes
Dirst. Do not use a
spacer with
powder for
inhalation. Use
Cautiously in:
Cardiovascular
disease
(including angina
and
hypertension);
Seizure
disorders;
Diabetes;
Glaucoma;
Hyperthyroidism;
Pheochromocyto
ma; Excessive use
(may lead to
tolerance and
paradoxical
bronchospasm);

81 mg 1 tab PO lower high blood Assess patient for

daily pressure signs of bleeding
(petechiae,
Asprin ecchymosis,
bloody or black
stools, bleeding
gums). Drink
adequate Dluids
while taking
aspirin. Advise
patient to avoid
alcohol when
prescribed high
doses of aspirin.
20 mg 1 tab PO For prevention PO: Administer

of once daily in the
cardiovascular evening. May be
disease and to administered
Pravastatin treat without regard to
(Pravachol) hyperlipidemia food. Avoid
grapefruit and
grapefruit juice
during therapy;
may increase risk
of toxicity. If
administered in
conjunction with
bile acid
sequestrants
(cholestyramine,
colestipol),
administer 1 hr
before or 4 hr
after bile acid
sequestrant.



Patient education and discharge teaching:

You have been diagnosed with chronic obstructive pulmonary disease (COPD).
Take your medicines exactly as directed. Don't skip doses.
Protect yourself from infectionWash your hands often. Do your best to keep your
hands away from your face. Most germs are spread from your hands to your
mouth.
Get a Dlu shot every year. Also ask your provider about pneumonia vaccines.
Stay away from crowds. It's especially important to do this in the winter when
more people have colds and Dlu.To stay healthy, get enough sleep, exercise
regularly, and eat a balanced diet. You should:Get about 8 hours of sleep every
night.Try to exercise for at least 30 minutes on most days.Have healthy foods
including fruits and vegetables, 100% whole grains, lean meats and Dish, and low-
fat dairy products. Try to stay away from foods high in fats and sugarYou have been
diagnosed with Hypertension.
Stay at a healthy weight. Get help to lose any extra pounds. Often times meeting
with a dietitian can help you identify changes that can be made to your diet to help
with weight loss. Learn to measure your own blood pressure. Keep a record of your
results. Ask your doctor which readings mean that you need medical attention.
Take your blood pressure medicine exactly as directed. Don’t skip doses. Missing
doses can cause your blood pressure to get out of control. The American Heart
Association (AHA) says the ideal amount of sodium is no more than 1,500 mg a
day. But because Americans eat so much salt, you can make a positive change by
cutting back to even 2,300 mg of sodium a day (1 teaspoon). You have been
diagnosed with Hyperlipidemia.
Maintain a healthy weight. Ask your healthcare provider how much you should
weigh. Ask him or her to help you create a weight loss plan if you are overweight.
Weight loss can decrease your cholesterol and triglyceride levels.
Exercise as directed. Exercise lowers your cholesterol levels and helps you
maintain a healthy weight. Get 30 minutes or more of aerobic exercise 4 to 6 days
each week. You can split your exercise into four 10-minute workouts instead of 30
minutes at one time. Examples of aerobic exercises include walking briskly,
swimming, or riding a bike. Work with your healthcare provider to plan the best
exercise program for you. Do not smoke. Nicotine and other chemicals in cigarettes
and cigars can increase your risk for a heart attack and stroke. Ask your healthcare
provider for information if you currently smoke and need help to quit. E-cigarettes
or smokeless tobacco still contain nicotine. Talk to your healthcare provider before
you use these products. Eat heart-healthy foods. Talk to your dietitian about a
heart-healthy diet. The following will help you manage hyperlipidemia:Decrease
the total amount of fat you eat. Choose lean meats, fat-free or 1% fat milk, and low-
fat dairy products, such as yogurt and cheese. Limit or do not eat red meat. Red
meats are high in fat and cholesterol

Procedures/Imaging (Please include results):
Nor Clie
Chemistry Normal Client’s Date Hematolo mal nt’s Date
Value gy Val Valu
ue e
Sodium 135-145 136 10/28/ RBC 4.5-5.0 4.5 10/28/
mEq/L 2020 2020
Potassium 3.5-5.0 4.3 10/28/ HGB 12-15 g/ 10 10/28/
mEq/L 2020 dL 2020
Chloride 95-105 101 10/28/ HCT 35-47 % 37 10/28/
mEq/L 2020 2020
C02 23-29 16 10/28/ MCV 78-102 94.4 10/28/
mEq/L 2020 μm3 2020
Calcium 8.5-10.5 8.7 10/28/ MCH 25-35pg 26 10/28/

mg/dL 2020 2020
Phosphorus 1.8-2.6 4.3 10/28/ MCHC 31-37% 32 10/28/
mEq/L 2020 2020
Cholesterol Less than 250 10/28/ WBC 4,500 to 5,000 10/28/
200 mg/dL 2020 11,00 2020
Albumin 3.4-5.4 3.7 10/28/ Neutrophil 55-70% 92% 10/28/
g/dL 2020 s 2020

BUN 8 to 25 27 10/28/
mg/dL 2020 Bands
Creatinine 0.6 to 1.3 1.25 10/28/ Eosinophil 1-4% 0.2 10/28/

mg/dL 2020 s 2020
Uric Acid Lymphocy 20-40% 3.7 10/28/
tes 2020
Magnesiu 1.6 to 2.6 2.3 10/28/ Basophils 0-2% 1.0 10/28/
m mg/dl 2020 2020
Bilirubin 0.3-1.0 1.2 10/28/ Monocytes 2-8% 2.2 10/28/
mg/dl 2020 2020
Amylase 25 to 151 27 10/28/ Platelets 150,000 to 354,000 10/28/
2020 400,000 2020
Lipase
Other
PTT
PTINR
Other:
Other:


Urinalysis Normal Value Client’s Date
Color Yellow Yellow 10/28/2020

Turbidity Clear Clear 10/28/2020
Specific Gravity 1.016 to 1.022 1.020 10/28/2020
Leukocytes Negative Negative 10/28/2020

Nitrite Negative Negative 10/28/2020
Urobilinogen 0.2-1.0 1.0 10/28/2020
Protein Negative Negative 10/28/2020
pH 4.5 to 7.8 5.5 10/28/2020
Blood Negative Negative 10/28/2020
Ketones Negative Negative 10/28/2020
Bilirubin Negative Negative 10/28/2020
Glucose >0.5g/day Negative 10/28/2020


Chemistry No Client’s Date Hematol No Clie Date

rm ogy rm nt’s
al al Val
Val Val ue
ue ue
Blood Osmolali 280 to 290 10/28/20
ty 300 20
Protein 6 to 8 g/dL 8 10/28/202 RDW
0
Bilirubin 0.3-1.0 1.0 10/28/202 MPV
0
Urobilinog 0.2-1.0 1.0 10/28/202 AIC-Hgb 11.6-16.4 15 10/28/20
en 0 20
Nitrate ALT 7-30 9 10/28/20
(SGPT) 20
Leukocytes AST 9-25 15 10/28/20
(SGOT) units/L 20
Cast 0-2 hyaline 1 10/28/202 PT 11-13 12 10/28/20
0 20
RBC 4.5-5.0 4.7 10/28/202 PTT 25-35 28 10/28/20
0 20
Crystals HDL 30-70 50 10/28/20
20
WBC 4,500 to 4,700 10/28/202 LDL Less 110 10/28/20
0 than130 20
Epithl 0-4 p,v,f 3p.v.f 10/28/202 VLDL
ial
Cells
0
CHOL/
HDL
Miscellane
ous
Vitamin D
TSH

LDH
Relate the clinical signiDicance of abnormal lab values above:

Psychosocial Assessment: Describe the client’s coping processes using the tenets of
Madeleine Leininger’s Culture Care Theory.

Culture Care Diversity and Commonalities

1. What are the commonalities between the patient’s cultural health
practices and the dominant cultural practices seen in the region? The
commonalities between the patient’s cultural health practices and the
dominant cultural practices seen in the region as both focus on the
healing and caring process. It includes the understanding of the cause,
preventive methods as well as promotion of the health. Both indulge in
perspective of improving the health conditions of the patients. There
are several similarities such as implementation of health elevation,
analyzing the cause and remove the factors and health disparities.
2. What are the observed DIFFERENCES between the patient’s cultural

health practices and the dominant cultural practices seen in the
region?In some communities fast for 18 hours, that will be a cultural
practice for them and mandatory for them, if the patient is suffering
from diabetes mellitus or gastric ulcers it will adversely affects the
treatment and the condition may worse, so the patient cultural health
practices and the dominant cultural practices inDluences the treatment.
Cultural & Social Structure

1. Economics impacting health:Social and economic factors such as education,
employment, income, social support and community safety inDluence the well and
how long we live, these factors affects our healthy decision in selecting food,
medical care and housing and living standards. The social and cultural
environment variables on health involves dimensions of both time as well as place.
2. Religious beliefs related to health: The religious beliefs sometimes affects the
health care system because some communities reject the medical treatment
including preventive measures like vaccinations, it will adversely affect the health
care systems groups reject some kind of foods that will also affects the health of
the individual.
3. Structure of support that may inDluence health: The government bodies helps the
health care system works effectively, the medical insurance and the other schemes of the
government policies also help the citizens get effective medical treatment.

Culture Care Preservation or Maintenance

1. Cultural Values that impact health:Cultural values are principles on which the
community exists. Culture is 4th pillar of sustainable development by UNESCO.
Culture values affects the beliefs and perceptions about causes of death, health
promotion, how illness and pain experienced and expressed.
2. Cultural Practices that impact health:Cultural practices lead to difference in
habitual conception of certain foods, differences in preparation and in some cultures milk
and meat are exempted from diet. Medical treatment like some cultures are against blood
transfusions.

Assessment of Behavior
Non-Observable (Subjective):DifDiculty Breathing Chest tightness patient stated "I can’t
breathe”
Observable (Objective): : Wheezing patients oxygen saturation level is down Blue/Gray
lips/Dingernails
Cultural Assessment:
Nursing Diagnosis #1 (Label, R/T and EB):Patient is showing decreased oxygen content,
decreased oxygen saturation Acute COPD exacerbation.

Goals/ Outcomes (include timeframes):

Short Term
1. Prevent disease progression
2. Prevent and treat complications
3.Relieve COPD symptoms
Long Term
1.Ongoing and reinforced education of the patient and lifestyle changes
2.Prevent & manage complications/exacerbations
3.Improve exercise tolerance/ health status
Nursing Interventions and Rationales (include citation):

1.Observe sign and symptoms of infections
2.Encourage abdominal or pursed-lip breathing exercises.
3.Assess and monitor respirations and breath sounds, noting rate and sounds (tachypnea,
stridor, crackles, wheezes). Note inspiratory and expiratory ratio.
4.Increase Dluid intake to 3000 mL per day within cardiac tolerance
Evaluation: Met/Not Met

Short Term:
1.Met
2.Met
3.Met
Long Term:
1.Met
2.Not Met
3.Met
Nursing Diagnosis #2 (Label, R/T and EB): Patient has elevated blood pressure exceeding
140 over 90 mmHg and has severe headaches Hypertension.


Short Term
1. Patient will verbalized his understanding of never stopping a medication
without the advice of a doctor.
2. Patient states they are no longer suffering from a headache
3.Patient appear comfortable and pain-free.
Long Term
1. Patient will maintain BP within individually acceptable range.
2. Patient will demonstrate stable cardiac rhythm and rate within patient’s normal range.
3. Patient will participate in activities that reduce BP/cardiac workload.

1. Monitor and record BP. Measure in both arms and thighs three times, 3–5 min
apart while patient is at rest, then sitting, then standing for initial evaluation
2. Observe skin color, moisture, temperature, and capillary reDill time.
3. Monitor response to medications to control blood pressure.
4. Auscultate heart tones and breath sounds.

Evaluation: Met/ Not Met

Short Term:
1.Met
2.Met
3.Met
Long Term:
1.Met
2.Met
3.Met
Nursing Diagnosis #3 (Label, R/T and EB): Patient has high levels of lipids (fats) in the
blood, including cholesterol and triglycerides and has been diagnosis with
Hyperlipidemia

Short Term
1. Eating a heart-healthy diet
2. Eat more Diber-rich foods, such as oatmeal, apples, bananas, pears, prunes,
kidney beans, chickpeas, lentils, and lima beans
3. Avoid sugary drinks and added sugars
Long Term
1.Losing excess weight
2.Quitting smoking
3.Becoming more physically


1. lower elevated blood cholesterol
2.Educate patient on hyperlipidemia
3. promotion of behavioral change,
4. monitoring dietary change and patient outcomes
Evaluation: Met/ Not Met (Provide rationale for evaluation outcome)

Short Term:
1.Met
2.Met
3.Met
Long Term:
1.Met
2.Met
3.Not Met

References
(Must include at least three; including the book)
https://www.webmd.com/hypertension-high-blood-pressure/default.htm
https://medlineplus.gov/copd.html https://www.mayoclinic.org/diseases-
conditions/hyperglycemia/symptoms-causes/syc- 20373631
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical
nursing: Hypertension, pg.720 Saunders.
Ignatavicius, D. D., & Workman, M. L. (2010). Medical-surgical
nursing: COPD pg.13 Saunders.


Care Plan 1 Med Surge

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NURSING

Patient Data Collection Form

Student Name: Ania Lobeto Date: 10/29/2020 Culture/Ethnicity:

Age: 67 Weight: 150 IB Language:English

Current Diagnoses (minimum of three with citations):

Revised September 18, 2018

Pathophysiology of Diagnoses (all):

Medical History: Diabetes

Surgical History: Hip replacement 2005

Vital Signs Time: 0938 Respiration Rate: 28 breaths

Revised September 18, 2018

Limitations/Prosthetic devices: N/A

Patient Assessment Form

Revised September 18, 2018

Intake (12 Hours) Total: 2000mL Output Total (12 Hours):1000mL

Revised September 18, 2018

Oral: 2000mL Voiding:N/A

Patient Data Collection Form

1. 1. Exacerbations can be severe and life

Revised September 18, 2018

2. 2. It's important to treat hyperglycemia,

3. 3. Early on, you may not notice symptoms of

Revised September 18, 2018

Patient Data Collection Form

Medication Dose Route/Time Rationale for Nursing

Revised September 18, 2018

40 mg 1 tab PO To increase If patient

Revised September 18, 2018

750 mg 1 tab PO To treat the nausea, vomiting,

Revised September 18, 2018

50 mcg 1inhalation Used for COPD Inhaln: Once

Revised September 18, 2018

81 mg 1 tab PO lower high blood Assess patient for

20 mg 1 tab PO For prevention PO: Administer

Revised September 18, 2018

Patient Data Collection Form

Revised September 18, 2018

Patient education and discharge teaching:

Revised September 18, 2018

Procedures/Imaging (Please include results):

Calcium 8.5-10.5 8.7 10/28/ MCH 25-35pg 26 10/28/

Revised September 18, 2018

Creatinine 0.6 to 1.3 1.25 10/28/ Eosinophil 1-4% 0.2 10/28/

Patient Data Collection Form

Patient Data Collection Form

American Medical Academy School of Nursing

Revised September 18, 2018

Urinalysis Normal Value Client’s Date

Color Yellow Yellow 10/28/2020

Leukocytes Negative Negative 10/28/2020

Revised September 18, 2018

Patient Data Collection Form

Chemistry No Client’s Date Hematol No Clie Date

Revised September 18, 2018

Relate the clinical signiDicance of abnormal lab values above:

Patient Data Collection Form

Revised September 18, 2018

Culture Care Diversity and Commonalities

2. What are the observed DIFFERENCES between the patient’s cultural

Cultural & Social Structure

Revised September 18, 2018

Culture Care Preservation or Maintenance

Patient Data Collection Form