Care Plan

Student: Madison McLuen Date: November 4th 2019

Course: NSG-320CC Instructor: Alyx Fergus

Clincial Site: Chandler Regional Medical Center Client Identifier: T.W. Age: 53

Reason for Admission: Multi-vessel disease

Client was admitted to the telemetry unit with exacerbation of multi-vessel disease and coronary artery disease (CAD). T.W. was admitted after
an outpatient abnormal stress test. She underwent a CABG after admission on on 10/27/19.

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

Coronary artery disease (CAD): CAD is caused by plaque build-up in Coronary artery disease (CAD): T.W.’s current clinical
the walls of the arteries that supply the coronary arteries and other parts of manifestations include shortness of breath, angina (chest pain), and
the body. This plaque is made up of cholesterol, causing the arteries to generalized fatigue and weakness.
narrow, partially or fully blocking blood flow, which is called Hypertension: T.W’s current clinical manifestations include
atherosclerosis. Risk factors include smoking, high blood pressure, high shortness of breath, multi-vessel disease, and history of stroke and
cholesterol, diabetes or insulin resistance, and a sedentary lifestyle (Mayo TIA.
Clinic, 2019)
Hypertension: This is a condition of persistent elevation of systemic
blood pressure (BP). It is a product of cardiac output and total peripheral
vascular resistance. Long-term force of blood against the artery walls is
high enough that it may cause heart disease or damage to blood vessels.
(Mayo Clinic, 2019). Hypertension can go easily undetected for years
without symptoms. Risk factors include over 65 years of age, family
history, obesity, excess sodium in the diet, stress, and various chronic
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
conditions.

Assessment Data
Subjective Data: T.W. complains of severe back pain, and states that she is unable to get out of bed or even turn over. She says that she is
tired and just wants to sleep. She describes her pain as a 7/10 on the numerical pain scale.
VS: T : 36.8 degrees C Labs: Taken on 10/31/19 Diagnostics:
BP: 115/74 WBC 10 XR chest 1 View Portable
HR: 67 bpm RBC 3.11 (L) Echocardiogram transthor w bubble study
RR:18 breaths/min Hgb 7.2 (L) CT chest wo Con
O2 Sat: 92% 3L/min nasal Hct 23.2 (L) Electrocardiogram
cannula
Glucose 221 (H) US vein mapping lower extremity Bil
Protein 5.7 (L) US Vase Dplx Extracran Art Bilat Comp
Albumin 2.9 (L)
ALT 983 (H)
AST 739 (H)
Iron 18 (L)
Sodium 136
Potassium 4.8

Assessment: Orders:

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General Appearance: Pale skin color, weak when ambulating, short of CBC w/o diff
breath
Basic metabolic panel
Mental Status Assessment: A&O X3
Continuous pulse oximetry
Speech is clear
Advance activity as tolerated
Skin: Cool to touch, dry, intact
Blood glucose monitoring POC
Pale color
Cardovascular: Regular rate and rhythm, no current abnormalities
Hx of paraxymal atrial fibrillation
Respiratory: Decreased breath sounds bilaterally
SOB, sternal dressing from CABG intact
Extremities: Vertigo when standing up
Mild peripheral edema bilaterally on lower extremities
Abdomen: Positive bowel sounds, soft, nontender, nondistended

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 Medications
ALLERGIES: amoxicillen, penecillens, & Phenergan
Name Dose Route Frequency Indication/Therapeutic
Effect
clopidogrel 75 mg PO Daily Reduction of atherosclerotic
events in patients at risk for
such events including recent
MI, acute coronary syndrome,
or peripheral vascular disease.
It inhibits platelet aggregation
by irreversibly inhibiting the
binding of ATP to platelet
receptors, thereby decreasing
the occurance of athersclerotic
events (Vallerand, Sanoski, &
Deglin, 2017).
Insulin lispro 0-8 units Subq w/ meals Control of hyperglycemia in
and HS patients with type 1 or type 2
diabetes mellitus. Lowers blood
glucose by stimulating glucose
reuptake in skeletal muscle and
fat, inhibiting hepatic glucose
production (Vallerand, Sanoski,
& Deglin, 2017).
Adverse Effects
Depression, cough, chest pain,
eeam, GI bleeding, SJS,
neutropenia, and dyspepsia
(Vallerand, Sanoski, & Deglin,
2017).
Hypoglycemia, hypokalemia,
erythemia, pruritis, swelling,
anaphylactic reaction (Vallerand,
Sanoski, & Deglin, 2017).
Nursing
Considerations
Monitor patient for
signs of thrombocytic
purpura.
Monitor CBC with
differential and platelet
count periodically
during therapy
Discontinue 5-7 days
before planned surgical
procedures
Advise patient to notify
the HCP if fever,
weakness, chills, sore
throat, rash, or unusual
bleeding occurs
Common side effects
inculde dizziness nad
hypotension (Vallerand,
Sanoski, & Deglin,
2017).
Assess for symptoms of
hypoglycemia (anxiety,
restlessness, tingling in
hands and feet, cold
sweats, confusion,
drowsiness, headache).
Monitor blood glucose
ever 6 hrs during
therapy, and more often
in times of stress.
Rotate injection sites
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meclizine 25 mg PO TID Used for management and
prevention of vertigo. Has a
central anticholinergic effect, a
CNS depressant, and
antihistamine properties. It
decreases the excitability of the
middle ear labyrinth to decrease
vertigo (Vallerand, Sanoski, &
Deglin, 2017).
metoprolol 25 mg PO Qday Used for hypertension and
management of stable,
symptomatic heart failure due
to ischemic, hypertensive nad
cardiomyopathic origin. It
blocks stimulation of beta1
receptors. It decreases BP and
heart rate (Vallerand, Sanoski,
& Deglin, 2017).
Drowsiness, fatigue, blurred
vision, and dry mouth
(Vallerand, Sanoski, & Deglin,
2017).
Fatigue, weakness, bradycardia,
HF, pulmonary edema, erectile
dysfunction, back pain, and
constipation (Vallerand,
Sanoski, & Deglin, 2017).
No common side
effects.
Instruct patient that
therapy is long-term.
Patient’s with diabetes
mellitus should carry a
source of sugar
Assess patient for level
of sedation after
administration
Assess degree of
vertigo periodically
Common side effect is
drowsiness. Caution
patient to avoid driving
or other activities that
require alertness
Advise patient that
frequent mouth rinses,
good oral hygiene, and
sugarless gum or candy
may decrease dryness in
the mouth (Vallerand,
Sanoski, & Deglin,
2017).
Monitor BP, ECG, and
pulse frequently during
those adjustment and
periodically during
therapy
Monitor intake and
output ratios and daily
weights
Common side effects
include weakness and
fatigue
Advise patient to
change positions slowly
to avoid orthostatic
hypotension (Vallerand,
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acetaminophen 650 mg PO Q4hrs PRN Treatment of moderate to
severe pain. Binds to opiate
receptors in the CNS and alters
the perception of and response
to painful stimuli while
producing generalized CNS
depression (Vallerand, Sanoski,
& Deglin, 2017).
pantoprazole 40 mg IV push Qday Indicated for erosive
esophagitis associated with
GERD. It binds to an enzyme in
the presence of acidic gastric
pH, preventing the final
transport of hydrogen ions into
the gastric lumen. It diminishes
accumulation of acid in the
gastric lumen, with lessen
gastric reflux (Vallerand,
Sanoski, & Deglin, 2017).
amiodarone 150 mg IV bolus Once Management of
Confusion, sedation, dizziness,
constipation, dry mouth, urinary
retention, physical dependence,
and N/V (Vallerand, Sanoski, &
Deglin, 2017).
Headache, clostridium difficile-
associated diarrhea, abdominal
pain, hyperglycemia, and
vitamin B12 deficiency
(Vallerand, Sanoski, & Deglin,
2017).
Bradycardia, hypotension,
Sanoski, & Deglin,
2017).
Assess type, location,
and intensity of pain
prior to and 1 hour after
administration
Assess BP, pulse, and
respirations before and
periodically during
administration. Physical
stimulation may be
sufficient to prevent
significant
hypoventilation.
Assess risk for opioid
addiction, abuse, or
misuse prior to
adminstration.
Common side effects
include drowsiness and
dizziness (Vallerand,
Sanoski, & Deglin,
2017).
Assess patient routinely
for epigastric or
abdominal pain and for
frank or occult blood in
stools
Monitor bowel
function. Diarrhea,
abdominal cramping,
fever, and bloody stools
should be reported to
the HCP immediately
Common side effects
include headache and
abdominal pain.
(Vallerand, Sanoski, &
Deglin, 2017).
Monitor ECG
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Nursing Diagnoses and Plan of Care
Goal Expected Outcome
Client or family focused. Measurable, time-specific,
reasonable, and attainable.
supraventricular
tachyarrhythmias. Prolongs
action potential and refractory
period, and slows the sinus rate,
and decreases peripheral
vascular resistance. Therapeutic
effect is suppression of
arrhythmias (Vallerand,
Sanoski, & Deglin, 2017).
Intervention(s)
Nursing or interprofessional Provide reason why intervention
interventions.
anorexia, constipation, nausea,
vomiting, increased liver
enzymes, ataxia, involuntary
movement, and peripheral
neuropathy (Vallerand, Sanoski,
& Deglin, 2017).
Rationale
is indicated/therapeutic.
Provide references.
continuously during IV
therapy or initiation of
oral therapy. Monitor
heart rate and rhythm
throughout therapy
Assess for signs of
pulmonary toxicity,
decreased breath
sounds, dyspnea, cough,
and wheezing
Monitor serum
potassium, calcium, and
magnesium prior to
starting and periodically
during therapy
Common side effects
include nausea and
vomiting (Vallerand,
Sanoski, & Deglin,
2017).
Evaluation
Was goal met? Revise the
plan of care according the
client’s response to current
plan of care.
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Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Acute pain related to operative procedure AEB 7/10 numerical scale rating and difficulty ambulating
This was chosen as the priority nursing diagnosis since the patient complained of pain, as well as the reason as to why she is unable to move or
ambulate out of bed. This puts the patient at risk for a longer period of immobility, which can lead to many other post-operative complications.
Patiet will rate pain on a scale of Patient will express relief from 1. Assess patient’s vital
1/10 (Phelps, Ralph, & Taylor, pain by the end of discharge signs and symptoms of
2017). (Phelps, Ralph, & Taylor, pain, and administer pain
2017). medication, as
prescribed. Monitor and
record the medication’s
effectiveness and
adverse effects.
2. Perform comfort
measures to promote
relaxation, such as
massage, bathing,
repositioning, and
relaxation techniques.
3. Manipulate the
environment to promote
periods of uninterrupted
rest. This promotes
health, well-being, and
increased energy level
important to pain relief
(Phelps, Ralph, &
Taylor, 2017).
1. Assessment allows for
careplan modification,
as needed.
2. These measures reduce
muscle tension or
spasm, redistribute
pressure on body parts,
and help patient focus
on non-pain related
subjects.
3. Provides rest period for
recovery and involves
the patient in their care
(Phelps, Ralph, &
Taylor, 2017).
Goal met:
1. Patient reports
achieving pain relief
with analgesia and
other measures.
2. Patient carries out
alternative pain
control methods
such as application
of heat and
relaxation
techniques.
3. Patient reports more
than 4 hours of sleep
nightly (less than 4
hours would require
further assessment)
(Phelps, Ralph, &
Taylor, 2017).

Secondary Nursing Diagnosis:

Risk for falls related to alteration in affective orientation
This was chosen as the secondary nursing diagnosis since the patient has a past medical history of vertigo, and also is 4 days post-op from a
CABG. Due to this, she is at an increased risk of falls due to blood pressure change when standing up or ambulating.
Patient will develop a strategy Patient will identify and 1. Spend time orienting 1. The patient’s Goal met:
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to maintain safety (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.”
eliminate 3 safety hazards in the patient and the
their home with the help of their family to the patient’s
family by the end of discharge environment. Assess
(Phelps, Ralph, & Taylor, the patient’s ability to
2017). use the call bell, or
other safety emergency 2.
systems. Remove
anything from the
environment that may
increase the risk of 3.
falls.
2. Identify factors that
may cause or
contribute to injury
from a fall.
3. Review medications
with the patient and
family. Help the
patient understand
which medications puts
the them at a higher
risk for falls. Knowing
the risk may help the
patient take more care
in moving about
(Phelps, Ralph, &
Taylor, 2017).
immediate 1.
environment must be
reviewed frequently to
prevent unnecessary
falls.
In order to enhance the 2.
patient, family,
caregiver awareness of
risks. 3.
Two are more
medications taken can
cause dizziness,
sleepiness, lowered
blood pressure, and
confusion.
Patient and family
were able to point out
things in the
environment that put
them at risk.
Patient demonstrated
the ability to move
without falling.
Patient and family
members provide
teach-back about
specific medications
that put them at greater
risk for falls, despite
her vertigo (Phelps,
Ralph, & Taylor,
2017).

References
Mayo Clinic. (2019). Coronary Artery Disease. https://www.mayoclinic.org/diseases-conditions/coronary-artery-disease/symptoms-

causes/syc-20350613

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Mayo Clinic. (2019). Hypertension (High Blood Pressure). https://www.mayoclinic.org/diseases-conditions/high-blood-

pressure/symptoms-causes/syc-20373410

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.

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