Care Plan

Student: Kiana Woods Date: 2/20/19

Course: NSG320CC Instructor: Diane Garlick

Clincial Site: Banner Boswell Medical Center Client Identifier: R.B. Age: 79

Reason for Admission:

On 2/16/2019, R.B. was admitted with complaints of a cough and difficulty breathing.

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

Lateral Pneumonia with Dyspnea The signs and symptoms of pneumonia may include
chest pain, cough, fatigue, fever, shortness of breath, and
• Pathophysiology: Lateral pneumonia, or pneumonia that affects only one
N/V (Mayo Clinic, 2018).
lung, is an infection often caused by a bacteria named Streptococcus
pneumoniae. During this infection, the air sacs or alveoli of the lungs, may Clinical manifestations R.B. presented with:
fill with fluid or pus and cause dyspnea, fever, a productive cough, and chills • Productive Cough
(Mayo Clinic, 2018).
• Difficulty breathing
• Risk factors: Some risk factors for developing pneumonia can include:
• Green-colored sputum
smoking, chronic disease such as asthma or COPD, those who are
• Chest soreness
immunocompromised, and those aged 65 or older (Mayo Clinic, 2018).
• Sore throat (from continuous coughing)
• Wheezing and crackles during expiration heard at
lung bases

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

 Assessment Data
Subjective Data:
• The patient spoke about coughing up “3 to 4 plugs of mucus” earlier that morning.
• After receiving her steroid medication, R.B. said: “I think the steroid are really helping with my cough.”.
• The patient denies using any oxygen while she is at home.
VS: T : 98.4 Labs: Diagnostics:
BP: 115/76 2/19 2/16 • CT angio chest w/ or w/o contrast on
WBC: 11.8 10.4 2/16/2019
HR: 95
RBC: 4.72 4.49 -Findings: No aneurysms or dissection.
RR: 18 HGB: 12.8 12.1 Focal atherosclerosis w/ mild stenosis.
HCT: 41.3% 39.2% Atherosclerosis in proximal left
O2 Sat: 92% on room air MCV: 88 87 subclavian artery without significant
MCH: 27.1 26.9 stenosis. Lunch parenchyma:
MCHC: 31 30.9 emphysematous changes in the lung.
RDW-CV: 13.8 13.6 Bilateral diffuse chronic interstitial
RDW-SD: 44.1 43.6 infiltrates. Bilateral multilobar bronchial
Nucleated RBCs: 0 0 wall mild thickening consistent with
Platelet: 285K 271K bronchitis.
MPV: 10.8 10.9 -Impressions: Bilateral multilobar
Glucose: 129 143 bronchial wall mild thickening consistent
BUN: 18.5 19.7 with bronchitis. Emphysematous changes
Creatinine: 0.83 0.78 in the lung. Bilateral diffuse chronic
Na: 138 141 interstitial infiltrates
K+: 4.6 4.5
Cl: 99 104
Co2: 29 27

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Assessment:
PMH: COPD, emphysema, nicotine dependence, Hx of breast cancer,
hypercalcemia, hyperlipidemia
Physical Assessment
Neuro:
• A&O x4
• Clear speech
• PERRLA. L pupil 3mm,
R pupil 3mm
• Eyes open to commands
• Cooperative affect
Cardiac (include VS):
• HR: 95, regular rate and
rhythm
• S1 and S2 auscultated
• Both radial and pedal
pulses palpable and 3+
bilaterally
• Cap refill less than 3
seconds
• No upper or lower edema
present
• JVD absent
Respiratory:
• 92% on room air
• Lung sounds: crackles and
wheezes at bases
bilaterally
Orders:
• Ambulate with assistance Q12h
• Skin and wound Education
• Education regarding tobacco cessation
• Delirium assessment Q12h
Skin/ Wound: • RSP medication
• Discontinue O2 on 2/20
• Intact, no wounds
• Full Code
• Color is appropriate for
ethnicity • Diet: Cardiac
• Warm, dry, and pink • Pulmonary physician: Shahid Yakoob
• Attending physician: Amir Khan
• Admitting physician: Habib Fala
Diet:
• Cardiac diet
I/O:
• Intake: 20mL IV 0.9%
normal saline, 0.75 mL
methylprednisolone,
600mL fluids
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 • Unlabored breathing • Output: Urinated 3 times,
• Productive cough- 1 BM on 2/20
green/thick mucus
GI: IV Lines/ Solutions:

•
Abdomen round and • Peripheral IV antecubital
nontender 20g – 0.9% normal saline
• Normoactive bowel
sounds
• Last BM: 2/20 (brown and
firm)
• Cardiac diet
• Blood glucose:
-7AM: 141 mg/dL AC
-12PM: 170 mg/dL AC
-4PM: 129 mg/dL AC
GU-Renal: MSK:

• Continent • Upper: moves against

• Clear, light yellow resistance, strong, and
• Urinated 3x on 2/20 equal
• No pain, difficulty, or • Lower: moves against
burning resistance, strong, and
equal
• Mobility: Up ad lib
• Assistive devices: walker
or cane
Fall precautions: No

Endocrine (accuchecks): Pain/ Nausea, etc.:

• Blood glucose: • Patient complains of a

• Q4h checks due to headache

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steroids • Precipitating: bright light
-7AM: 141 mg/dL AC and loud voices
(before breakfast) • Quality: Sharp and
-12PM: 170 mg/dL AC throbbing
(before lunch) • Radiation: No
-4PM: 129 mg/dL AC • Region: head
• Severity: 3/10
• Goal: 1/10
• Alternative pain control
methods: turning off the
lights, cold towel on
forehead

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 Medications
ALLERGIES:
• Lipitor: muscle spasms
• Crestor: rash/hives
• Statins: rash
• Codeine: vomiting and itching
• Darvon: vomiting and itching
• Latex: rash
• Zocor: muscle pain
Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing Considerations
Effect
Acetylcysteine 0.4gm=2mL Nebulized BID Indication: management of Drowsiness, Nursing: Assess respiratory function
conditions with thick viscid vasodilation, (lung sounds and dyspnea) before
mucous secretions. hypotension. and after administration
Therapeutic: Lowers the Tachycardia, Nursing: Assess and ask questions
viscosity of mucus bronchopasm, N/V regarding mucus color, smell,
(Vallerand, Deglin, & (Vallerand, Deglin, & amount, and consistency
Sanoski, 2017) Sanoski, 2017) Nursing: Monitor cardiac function
and blood pressure.
Education: Advise the patient to
change positions slowly to minimize
orthostatic hypotension
Education: Instruct patient to clear
airway by coughing deeply before
taking aerosol treatment.
Education: Inform patient that
unpleasant odor of this drug becomes
less noticeable as treatment
progresses and medicine dissipates.
(Vallerand, Deglin, & Sanoski, 2017)
3mL Nebulized Q6h Indication: Prevention of Nervousness, Nursing: Monitor patient’s blood
Albuterol-ipratropium bronchospasm hyperglycemia, chest glucose before and after treatment
Therapeutic: pain, HA, Nursing: Assess patient’s BP before
Bronchodilation hypertension, tremor, and after treatment
(Vallerand, Deglin, & N/A, hypokalemia Nursing: Observe for paradoxical
Sanoski, 2017) (Vallerand, Deglin, & bronchospasm (wheezing). If
Sanoski, 2017) condition occurs, withhold
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 medication and notify health care
professional immediately.
Education: Caution patient not to
exceed recommended dose; may
cause adverse effects, paradoxical
bronchospasm (more likely with first
dose from new canister), or loss of
effectiveness of medication.
Education: Inform the patient that
they may experience nervousness,
tremors, and restlessness after the
treatment
Education: Inform patient that
albuterol may cause an unusual or
bad taste.
(Vallerand, Deglin, & Sanoski, 2017)
81mg PO QD Indication: reduces Tinnitus, GI bleeding, Nursing: Monitor liver function
Aspirin inflammation and pain N/V, hepatotoxicity, Nursing: Assess bowel sounds and
Therapeutic: reduction of rash, hemolysis lightly palpate abdomen to see if
inflammation and pain (Vallerand, Deglin, & patient is experiencing any pain.
(Vallerand, Deglin, & Sanoski, 2017) Nursing: Pain assessment before and
Sanoski, 2017) after administration (if being used
for pain)
Education: Teach patient to avoid
alcohol, may cause GI bleeding or
irritation
Education: Advise patients that
Aspirin may need to be withheld for
1 wk before surgery.
Education: Advise patient to report
tinnitus; unusual bleeding of gums;
bruising; black, tarry stools; or fever
lasting longer than 3 days.
(Vallerand, Deglin, & Sanoski, 2017)
40mg SubQ Q24h Indication: Prevention of HA, dizziness, urinary Nursing: Assess patient’s I/O to
Enoxaparin venous thromboembolism retention, watch for urinary retention
Therapeutic: Prevention of hyperkalemia, Nursing: Assess bowel sounds due to
thrombus formation constipation, fever, risk for constipation
erythema at injection
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 (Vallerand, Deglin, & site (Vallerand, Deglin, Nursing: Assess the injection site
Sanoski, 2017) & Sanoski, 2017) before and after administration.
Rotate injection sites.
Education: Advise patient to report
any symptoms of unusual bleeding
or bruising, dizziness, itching, rash,
fever, swelling, or difficulty
breathing
Education: Instruct patient not to
take aspirin, naproxen, or ibuprofen
without consulting health care
professional while on enoxaparin
therapy.
Education: DVT prevention
education
(Vallerand, Deglin, & Sanoski, 2017)
600mg PO BID Indication: Coughs Dizziness, HA, rash, Nursing: Assess color, consistency,
Guaifenesin associated with viral upper urticaria, stomach and amount of mucus
respiratory tract pain, N/V Nursing: Assist patient during
infections. (Vallerand, Deglin, & ambulation if they have experienced
Sanoski, 2017) dizziness from this medication
Therapeutic: Mobilization Nursing: Assess lung sounds and
and subsequent frequency of cough
expectoration of mucus. Education: Teach the patient to spit
out any mucus they may cough up
(Vallerand, Deglin, & Education: Instruct patient to cough
Sanoski, 2017) effectively. Patient should sit upright
and take several deep breaths
before attempting to cough.
Education: Inform patient that drug
may occasionally cause dizziness.
Avoid driving or other activities
requiring alertness until response to
drug is known.
(Vallerand, Deglin, & Sanoski, 2017)
30mg=0.75mL IV push Q12h Indication: Suppresses HA, hypertension, Nursing: Suggest potassium
Methylprednisolone inflammation depression, fluid supplements or an increase of
retention,
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 Therapeutic: Suppression restlessness, potassium-rich foods unless
of inflammation hyperglycemia, N/V, contraindicated
(Vallerand, Deglin, & slow wound healing, Nursing: Monitor blood glucose
Sanoski, 2017) hypokalemia frequently
(Vallerand, Deglin, & Nursing: Assess patient’s BP before
Sanoski, 2017) and after administration
Education: Glucocorticoids cause
immunosuppression and may mask
symptoms of infection. Instruct
patient to avoid people with known
contagious illnesses and to report
possible infections immediately.
Education: Caution patient to avoid
vaccinations without first consulting
health care professional.
Education: Encourage patient to eat
a diet high in protein, calcium, and
potassium, and low in sodium and
carbohydrates
(Vallerand, Deglin, & Sanoski, 2017)
750mg PO Q48h Indication: Treatment of Hepatotoxic, seizures, Nursing: Assess for infection (vital
Levofloxacin pneumonia suicidal thoughts, signs; appearance of wound,
Therapeutic: Death of hyperglycemia, sputum, urine, and stool; WBC;
susceptible bacteria arthalgia, N/V, urinalysis; frequency and urgency of
(Vallerand, Deglin, & vaginitis, confusion, urination; cloudy or foul-smelling
Sanoski, 2017) dizziness urine) at beginning of and during
(Vallerand, Deglin, & therapy.
Sanoski, 2017) Nursing: Assess for suicidal
tendencies, depression, or changes
in behavior periodically during
therapy.
Nursing: Monitor bowel function
Education: May cause dizziness and
drowsiness. Caution patient to avoid
driving or other activities requiring
alertness until response to
medication is known.

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Education: Advise patient to report
signs of superinfection (furry
overgrowth on the tongue, vaginal
itching or discharge, loose or foul-
smelling stools).
Education: Advise patient, family,
and caregivers to look for suicidality,
especially during early therapy or
dose changes
(Vallerand, Deglin, & Sanoski, 2017)

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 Nursing Diagnoses and Plan of Care
Goal Expected Outcome Intervention(s) Rationale Evaluation
Client or family focused. 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.
Priority Nursing Diagnosis (including rationale for choosing this as the priority diagnosis)
Ineffective breathing pattern related to lateral pneumonia as evidenced by dyspnea and decreased oxygen
saturation.
Rationale: Using the ABC priority rule, airway and breathing issues are top priority and have compromised R.B.’s oxygen status and have caused difficulty breathing, both
of which can lead to more serious complications.

1. Assist patient into a 1. These meausres I was unable to assess if the

The goal is to improve the
patient’s breathing pattern.
Before the patient is comfortable position. promote comfort, chest goal was met.
discharged, R.B. will report an 2. Provide rest periods expansion, and
improvement in her breathing between breathing ventilation of basilar
pattern by rating her level of enchancement lung fields.
dyspnea daily. measures. 2. This will avoid fatigue
3. Teach patient about 3. To improve the
pursed-lip breathing patient’s breathing
(Phelps, Ralp, & Taylor, 2017). pattern.
(Phelps, Ralp, & Taylor, 2017).

Secondary Nursing Diagnosis:

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Risk for future respiratory infection related to chronic illnesses and lifestyle behaviors as evidenced by her past
diagnoses of COPD, emphysema, and tobacco dependence.
The patient will understand By the end of my shift, using 1.Encourage fluid intake of 3-
respiratory infection the teachback method, the 4000 mL daily unless
prevention. patient will list 3 ways to contraindicated.
prevent respiratory infections.
2.Teach patient about:
handwashing, factors that
increase risk, and s/s of
infection.
3.Teach patient the importance
of smoking cessation
(Phelps, Ralp, & Taylor, 2017).
1.This will help thin mucus The goal was met before the
secretions end of my shift.
2.These measures allow patient
to participation in their care
and help the patient modify
their lifestyle to maintain
optimum health.
3.As smoking puts the patient
at risk for respiratory infections
(Phelps, Ralp, & 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.”

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 References

Mayo Clinic. (2018, Mar 13). Pneumonia. Retrieved from

https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204

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

PA: Wolters Kluwer.

Vallerand, A. H., Deglin, J. H., & Sanoski, C. A. (2017). Davis's drug guide for nurses (15th ed.). Philadelphia, PA: F.A. Davis

Company.

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