NURSING CARE PLAN
Patient: ___FV____________
Medical Diagnosis: ___r/o ACS, MI, CHF, PE_________
Co-Morbidities: __ ESRD, renal transplant, HTN, DM II, uterine cancer, hysterectomy, brain lymphoma, craniotomy, HLD, thyroid disease, partial
thyroidectomy, cholecystectomy
Nursing Supporting Assessment
Diagnosis Data
SUBJECTIVE:
“Ouch!”
“I can’t change position in
bed because my head
PAIN hurts”
“I like the head of bed up
because my head hurts”
“My head hurts so bad”
“I just want this to go
away”
“Can I have some pain
med?”
“The light and noise made
my head hurts”
“my chest pain is better,
it’s mostly my headache
now”
OBJECTIVE:
10/10
Throbbing, mostly on the
left side of the head
Facial grimacing, hugging
the head
Moaning
RR 20
O2 sat 88% on RA  91%
2L NC
Nursing Interventions Expected Patient Evaluation
Outcome
Monitor: Outcomes: Pt goal met, pt
VS, hold if RR <10. BP 123/85, HR 91, RR20, O2 sat 88% Pt uses pharm and stated “I feel
on RA  91% 2L NC non-pharm pain relief much better
PQRST characteristics of pain (constant throbbing pain, strategies now”, “I can sit
L side of head without radiation, 10/10, started 3am up to eat lunch
this morning) Pt will have a now”, and “my
Hx of this pain, has it happened before, how did she decrease in pain level pain has gone
manage it? Any allergies or known SE to meds taken? to a tolerance pain down to 5/10,
What does having this pain mean to the pt? level 7-8/10 which is
Monitor CNS changes before and after med tolerable now.”
administration (dizziness, drowsiness, LOC, pupil Pt can comfortably
reaction) perform ADLs
Assess renal (BUN 19/Cr 1.2) and liver function (AST 41, without ..
Albumin 3.1), glucose (122), WBC (5.9), H/H
(12.6/39.9), NA/K (137/3.4) Pt can relax in bed
Bowel status because opioid pain meds can cause without facial
constipation (last BM yesterday) grimacing and
Checking PQRST of the headache again 30 min-1 hr moaning
after administration of the med, and physical
dependency. Stable VS
CT Head without contrast – result no abnormal
findings, focal encephalomalacia in high L parietal lobe Relaxed muscle tone
r/t prior tumor resection, no hemorrhage or mass. and body posture
Recommended MRI for further confirmation
Pt displays
Manage: improvement in
mood, coping
Non-pharmacological interventions: distraction (TV,
 Pt has been receiving
Norco 5/325 mg and
Tylenol 650mg
Nursing Supporting Assessment
Diagnosis Data
SUBJECTIVE:
“I had a chest pain
yesterday but now it’s
more about my headache”
Perfusion “I have a cough and sore
r/t PE throat”
“I get tired when I go to
the bathroom”
“I can’t breath if I lay flat”
OBJECTIVE:
7/10
Tremors
Productive cough
CXR shows lower left base
atelectasis bilaterally
Crackles on left lower lobe
16 V-tach detected on the
tele box monitor while pt
ambulated to the
music), reduce noise/light, relaxation, meditation,
massage, immobilization
Pharmacological interventions:
Norco 5/325 PRN q4hr for moderate/severe pain
Tylenol 650mg PRN q4hr for mild pain
Teach:
Tell pt to report any SE of hydrocodone/acetaminophen
such as drowsiness, dizziness, sedation, change in BP,
brady/tachycardia, n/v, constipation, resp depression
Report any S&S of CNS changes, allergic rxn, avoid CNS
depressant
Teach pt that dizziness and drowsiness are common,
avoid getting up without assistance, call for help.
Nursing Interventions Expected Patient Evaluation
Outcome
Monitor: Patient maintains Patient is alert
Mental status (A/Ox4), chest pain, dyspnea (SOB upon adequate gas and awake,
exertion), headache, hypercapnia, hypoxia, pale skin, exchange, O2 sat A/O x4,
restlessness, respiratory rate (RR20, unlabored >92%, remains alert maintains
breathing, chest expansion symmetrical), Nail beds with no further bedrest with
(pink), mucous membranes (oral thrush with white deterioration in LOC, bathroom
patches on the tongue) maintains effective privileges, O2
Changes in VS (BP 123/85, HR 91, RR20, O2 sat 88% on breathing pattern with sat 91% on 2L
RA  91% 2L NC) relaxed, nonlabored NC considering
Heart sounds (S1, S2 regular rhythm, no murmur, no breathing at normal pt was talking
extra heart sounds) rate and depth with with family,
Lung sounds (Crackles on both lower lobes) absence of dyspnea, unlabored
Edema (no edema on any extremities) baseline HR (<100) breathing with
Radial pulses weak 1+ bilaterally, pedal pulses strong 2+ D-dimer decreases RR 19 and calm
Cap refill <3sec on all extremities towards negative attitude, non-
Monitor for occurrence of cough with pink, frothy value (<.5), and lower dyspneic while
sputum BNP. in bed, HR 91,
Check for blood culture, urine culture, sputum C&S D-dimer
order, recommend ABGs order from MD decreased
Follow up with CT Angiogram, Doppler, and VQ scan from 1.66 to
bathroom status 1.00
Echo shows EF 65% H/H (12.6/39.9), PLT (196), PTT (therapeutic goal 55-80)
EKG shows normal wave PTT 81 (higher than goal)  decrease from 900 to 800
ranges, regular sinus ml/hr
rhythm Check for bleeding S&S (gums, black tarry stools,
Trop .015 hematuria, decrease H/H, BP)
D-dimer 1.66 Manage:
BNP 360
O2 sat 88% on RA and 91% Non-pharmacological interventions: encourage bedrest
on 2L NC with bathroom privilege, position high fowler in bed
with HOB >45 degree, SCD/compression stockings after
Doppler confirms no DVT

Pharmacological interventions: oxygen therapy, heparin

drips/ASA to prevent blood clots

Teach:
SE of heparin such as increase bleeding time,
hematuria, fever, headache, rash, hyperlipidemia
Avoid OTC meds, NSAIDS
Use soft-bristle toothbrush to avoid bleeding gums
Repost any S&S of bleeding: gums, under skin, urine,
stools, unusual bruising even after d/c drug
Report any changes in mental status, SOB, palpitation,
chest pain.
Encourage activity as tolerated