Care Plan

Student: Ahsan Arca Date: 1/21/2020

Course: NSG-430CC Instructor: Sheila Arnberger

Clincial Site: Banner Del Webb: 3D PCU Client Identifier: G.G. Age: 78 y/o

Reason for Admission: G.G. came into the ER on 1/20/20 at 1146 with left-sided chest pain radiating to the left arm and SOB. He was then
transferred to PCU for cardiac monitoring on the same day at 2100.

Medical Diagnoses: (Include Pathophysiology and Risk Factors [r.f.]):
NSTEMI: occurs when the blood flow through the heart is compromised,
which can be the result of a plaque build up in the arteries from fat or
blood clots. When the artery lumen is narrowed from fat, substances
from the blood, such as cholesterol or blood clots can cause a blockage.
This type of MI means that there was a “partial blockage” in the arteries.
Some r.f. include: diabetes, high cholesterol levels, metabolic syndrome,
and stress (“Mayo Clinic”, 2019).
Clinical Manifestations (C.M.):
G.G. experienced tightness in his chest that “radiated” to his arms,
shortness of breath, coughing, and heart burn.
Other C.M. include: fatigue, light-headedness, and cold sweat
(“Mayo Clinic”, 2019).

Assessment Data

Subjective Data: “I came into the ER because my chest was hurting all the way to my left arm. I was having a hard time breathing. 3 days
ago, I fell on my side and I thought that the pain was because of the fall.”.

VS: Labs: Diagnostics:

1/21/20 at 0830 Taken on 1/20/20 at 1235: Taken on 1/20/20.
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
T : 36.8 C Troponin 116ng/L. Chest x-ray: lungs and pleural space are clear. Tortuous
calcified aorta. Enlarged heart with pulmonary vascular
BP: 117/88 bpm Taken on 1/20/20 at 2018:
congestion status.
HR: 57 bpm Troponin: 140ng/L (normal: 0-0.4ng/L). This
CT Angio/abd/pelvis: atherosclerotic aorta without
number is high due to heart damage; troponin is
RR: 16 breaths/min aneurysm. Patent major branch vessel.
“released” when injury in the heart occurs. High
O2 Sat: 96% on RA (room number implies myocardial infarction (“AACC”,
air). 2019).
Pain: 10/10 pain on L, lateral *CK-MB level was not taken.
trunk.
Normal values reference (Lewis, Bucher,
1/21/20 at 1030 Heitkemper, Harding, Kwong, & Roberts, 2017).
T : 36.8 C
BP: 149/80
HR: 64 bpm
RR: 20 breaths/min
O2 Sat: 95% on RA
Pain: 7/10 pain on L, lateral
trunk.

Assessment: Orders:
PMH: acute MI, CAD, and HTN. NPO after midnight on 1/21/20 for cardiac catherization procedure
on 1/22/20 at 1000.
Neuro: A&Ox3. PERRLA noted, and pupil size 3mm b/l (bilaterally).
Glasgow coma score of 14. He was responsive and cooperative. Cardiac Monitoring.

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Respiratory: dry cough present. Respiration labored, short, and quiet
at 20 breaths/min. He sat upright, with legs dangling on side of bed.
Breath sounds were clear to auscultation in all lobes b/l, but
diminished at lower lobes b/l.
Cardiovascular: nail beds color are pink and appropriate to ethnicity.
Capillary refill <3sec b/l in UE and LE. Heart rhythm was regular; s1 and
s2 hurt, with no murmurs or bruit. Cardiac rhythm was NSR. Dorsalis
pedis pulses and radial pulses approximately 2+ b/l.
GI: rounded, firm, and nontender abdomen. Normal bowel sounds in
all 4 quadrants. Last BM was on 1/21/20 at approximately 0730. He is
on a cardiac diet.
GU: voids independently. I&O not found on the chart for the day.
Musculoskeletal: ambulate independently. ROM equal in UE and LE b/l.
Compression stockings/devices not implemented.
Integumentary: warm, dry, and intact skin. Color appropriate to
ethnicity. Skin lesions present on upper dorsal thorax. Skin turgor
appropriate. Mucous membrane was pink and moist.
Lines: peripheral IV in the R AC; 20G. Dressing was dry and intact.

Medications
ALLERGIES: NKA
Wt: 96.1kg
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 Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
81mg, 1 PO Once daily “Prophylaxis of transient GI bleed, tinnitus, and Warn patient
Aspirin (Aspir-Low) tab ischemic attacks and MI” hemolysis (Vallerand & regarding alcohol
(Vallerand & Sanoski, Sanoski, 2017). use while on
2017, p.1). medication. Teach
Therapeutic effect: client to sit up for
“decreases platelet 15-30minutes after
aggregation” (Vallerand & administration.
Sanoski, 2017, p.1110). Take with food to
reduce gastric
upset. Common s.e.
include dyspepsia,
stomach upset, and
nausea (Vallerand
& Sanoski, 2017).
100mg SQ Q12h Used for prevention of Osteoporotis, Assess for any signs
Enoxaparin (Lovenox) complications in NSTEMI. thrombocytopenia, of bleeding, such as
Therapeutic effect: eosinophilia (Vallerand & black tarry stools.
“potentiates the Sanoski, 2017). Teach client to
inhibitory effect of monitor and report
antithrombin” (Vallerand bleeding, SOB, and
& Sanoski, 2017, p.632). rash. Alternate
sites of injection to
prevent skin
breakdown.
Common s.e.
include bleeding,
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 vomiting, and
anemia (Vallerand
& Sanoski, 2017).
12.5mg PO BID Used to decrease the rate Pulmonary edema, HF, and Assess BP and ECG
Metoprolol of mortality in patients memory loss (Vallerand & to note changes.
(Metoprolol Tartrate) with MI. Sanoski, 2017). Teach I&Os and
Therapeutic effect: monitor for s/s of
“blocks stimulation of HF. Teach client not
beta1 receptors” to to abruptly stop
decrease BP (Vallerand & medication, as
Sanoski, 2017, p.839). complications may
occur. Common s.e.
include: erectile
dysfunction,
weakness, and
fatigue (Vallerand
& Sanoski, 2017).
Acetaminophen 650mg, 2 PO Q4h; pain To manage mild pain Hepatotoxicity, Stevens- Advise client to
(Tylenol) tab level 1-3; treatment (Vallerand & Johnson syndrome, and avoid alcohol while
last given Sanoski, 2017). pancytopenia (Vallerand & on therapy.
1/21/20 at Therapeutic effect: blocks Sanoski, 2017). Monitor client’s
0946 the synthesis of temperature for
prostaglandins (Vallerand effectiveness.
& Sanoski, 2017). Advise client to
take ordered dose
to avoid toxicity.
Common s.e.
include insomnia,
nausea, and
vomiting (Vallerand
& Sanoski, 2017).

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Atorvastatin (Lipitor) 40mg, 1 PO Once daily Used for management of Rhinitis, myalgia, and Assess patient’s
tab hypercholesterolemia. arthritis (Vallerand & triglyceride levels
Therapeutic effect: Sanoski, 2017). after therapy.
“inhibits 3-hydroxy-3- Inform client to
methylglutaryl-coenzyme report muscle
A (HMG-CoA) reductase, weakness or
an enzyme which is unexplained pain to
responsible for catalyzing the HCP,
an early step in the immediately.
synthesis of cholesterol” Monitor CPK levels
(Vallerand & Sanoski, throughout
2017, p.640). therapy. Common
s.e. include:
diarrhea,
abdominal cramps,
and flatus
(Vallerand &
Sanoski, 2017).
Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. Measurable, time- Nursing or interprofessional Provide reason why Was goal met? Revise
specific, reasonable, and interventions. intervention is the plan of care
attainable. indicated/therapeutic. according the client’s
Provide references. response to current
plan of care.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Decreased cardiac output r/t altered contractility AEB constant dry coughing and dyspnea.
This was chosen as the priority diagnosis, as blood transport from the heart is crucial for supplementing the whole body in oxygen and
nutrients, a “basic need” according to Maslow’s Hierarchy of needs (Friberg & Creasia, 2016).
The patient will have a 1. “to detect cerebral The goal was partially

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 blood pressure between 1. “Monitor and record hypoxia resulting from met.
The patient will present 120/80-140/90 by the end LOC, heart rate and decreased cardiac 1. The client was
with arrhythmias. of the shift. rhythm, and blood output” (Phelps, Ralph, monitored for
pressure, at least every & Taylor, 2017, p.47). LOC, and VS
4 hours” (Phelps, Ralph, 2. “Extra heart sounds twice only
& Taylor, 2017, p.47). may indicate early during the shift.
2. “Auscultate for heart cardiac 2. The client’s
and breath sounds at decompensation; breath sounds
least every 4 hours. adventitious breath and heart
Report abnormal sounds may indicate sounds were
sounds as soon as they pulmonary congestion assessed three
develop” (Phelps, Ralph, and diminished cardiac times during the
& Taylor, 2017, p.47). output” (Phelps, Ralph, shift.
3. “Inspect for pedal or & Taylor, 2017, p.47). 3. The client was
sacral edema” (Phelps, 3. “to detect venous evaluated for
Ralph, & Taylor, 2017, stasis and reduced signs of edema.
p.47). cardiac output”
(Phelps, Ralph, &
Taylor, 2017, p.47).
Secondary Nursing Diagnosis:
Deficient knowlwdge r/t insufficient information AEB reoccurence of disease process, according to PMH.

He will verbalize 3 lifestyle
The patient will show an changes, to avoid further
understanding of cardiac complications of current
diseases. illness, by the end of the
shift.
1. “Establish 1. “Comfort with growing The goal was partially
environment of self-awareness, ability met.
mutual trust and to share this 1. A comfortable
respect to enhance awareness with environment was
learning” (Phelps, others, receptiveness provided to client and
Ralph, & Taylor, 2017, to new experiences, allowed him to adjust
p.197). and consistency to new caregivers.
2. “Negotiate with between actions and 2. Client’s goals was not
patient to develop words” (Phelps, Ralph,
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 goals for learning” & Taylor, 2017, p.197). discussed.
(Phelps, Ralph, & 2. “Involving patient in 3. Resources were not
Taylor, 2017, p.197). planning meaningful provided to the client.
3. “Provide patient with goals encourages
names and telephone follow through”
numbers of resource (Phelps, Ralph, &
people or Taylor, 2017, p.197).
organizations” (Phelps, 3. “to provide continuity
Ralph, & Taylor, 2017, of care and follow-up
p.197). after discharge”
(Phelps, Ralph, &
Taylor, 2017, p.197).
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.”

References

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AACC. (2019). Troponin. Retrieved from https://labtestsonline.org/tests/troponin

Friberg, E. E., & Creasia, J. L. (2016). Conceptual foundations: The bridge to professional nursing practice (6th ed.). St. Louis, MO.

Lewis, S., Bucher, L., Heitkemper, M., & Harding, M. (2017). Medical-surgical nursing (10th ed.). St. Louis, MO.

Mayo Clinic. (2019). Heart attack. Retrieved from https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-

causes/syc-20373106

Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD.

Vallerand, A., & Sanoski, C. (2017). Davis’s drug guide for nurses (15th ed.). Philadelphia, PA.