Care Plan

Student: Alexandria Casarez Date: 03/01/2020

Course: 320 CC Instructor: Leigh Ann Tovar

Clincial Site: Banner Del Webb Client Identifier: BW Age: 78

Reason for Admission: Patient was addmited to the observation floor on 2/29/2020 due to nausea and vomiting, weakness, dehydration, and
diarrhea.

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

The reason for admission for this patient discussed nausea and
vomiting and was resolved as of 3/1/20. The morning of the 1st
patient complained of difficulty swallowing. The medical
diagnosis related to the difficulty of swalowing is a
cerebrovascular accident (CVA). A CVA can also be called a
stroke, and it occurs when there is a interuption of blood flow to
the cranial tissues. Risk factors for stroke include modifyable and
nonmodifiable. The modifiable risk factors include hypertension,
heart disease, diabetes, smoking, obesity, poor diet, and drug and
alcohol use. The nonmodifiable risk factor include age, gender,
ethnicity, family history or hereditary (Harding et. al, 2017).
Clinical manifestation of a stroke includes affecting many body
functions. These bodily functions include motor activity, bladder
and bowel elimination, intellectual function, spatial-perceptual
channges, sensation, swallowing, and communication(Harding et.
al, 2017). Depending which artery is affected can cause ischemia to
different parts of the brain and the clinical manifestations may be
specific to that area of the brain.

Assessment Data
Subjective Data: Patient was talkative and cooperative when talking with nurses and doctors. Patients patient expressed gratitue and comfort
to nursing staff while assisting her. Patient complained of pain in leg and arm related to left sided hemiplagia.
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
VS: T : 36.4 ° C Labs: Diagnostics:
BP: 110/73 -Complete Blood Count No diagnostics were found in the patients chart that
related to the reason for admission.
HR: 104 RBC-4.42
RR: 18 WBC-8.3
O2 Sat: 99% on room air HGB-13.5
HCT-41.6%
MCV-94
MCH-30.5
MCHC-32.5
-Chem Gener
Glucose-150 mg/dL (H)
BUN-15
Creatinine-0.97
GFR-56 (L)
Na-141
K-3.5
Cl- 107
Co2-23
Anion Gap- 11
Ca-8.3 (L)

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Assessment: Orders/Safety Protocols:

Neuro: Patient was alert and oriented x4 patients speech was clear and -ambulate with assistance
appropriate. Patients pupils were equal, round, reactive to light, and -full code
accommodation was notted. Eyes opened to verbal commands, and
patient had a cooperative affect. -precasutions for allergy to latex

Repiratory: Patients O2 was 99% on room air, patients lung sounds -fall precautions
were clear throughout all lobes with unlabored breathing.
-soft food diet
Cardo/ Vascular: Heart sounds were auscultated for all valves, S1 and
-patient has order to be NPO after midnight on 03/01/2020 @ 23:59
S2 were noted with regular rate and rhythm. Patients radial and pedal
MST
pulses were noted at 2+ bilaterally. Capillar refil was less that 3 seconds
in both fingers and toes. No edema was noted in the patients upper and
lower extremity.
GI: Patients stomach is flat, and non-tender, bowel sounds were
normoactive.
GU: Patient voids without pain and urine is a darker yellow and without
sediment, with a strong oder.
Skin: Patients skin appeared consistent with ethnicity, skin was intact,
and warm.
Hygine: Patient preforms parital bed bath on self as needed.
Pain: Patient does not complain of pain at the moment.
Lines and IV’s: Patient has a 20g IV catheter in right antecubital.

Medications
ALLERGIES: Patient has alergies to latex, no known drug allergies.

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 Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Albuterol-ipratropium 3mL Nebulizer Q 6 hrs Used as a bronchodialator to Nervousness, restlessness, Assess lungs sounds,
(DuoNeb) control and prevent revirsible tremor, chest pains, palpatations, pulse, and BP before
airway obstruction. and arrythmias administrations and
throughout therapy.
Observe for paradoxical
bronchospasm.
Asprin 81 mg PO Daily Blood thinner, and fever Heart burn, bleeding, Monitor hepatic
reducer. hepatotoxicity, and anaphylaxis function and serum
levels for drug toxicity.
Atrovasatin 80 mg PO Q bedtime Secondary prevention of Amnesia, confusion, dizziness, Obtain a dietary history,
cardiovascular disease by HA, insomnia, abdominal especially with regards
decreasing risk of MI, stroke, cramps, constipation, diarrhea, to fat consuption.
and angina. heartburn, and blurred vision Instruct patient to take
the medicationas
directed, to not skip or
double up on doses.
Galbapentin 200 mg PO Daily Used for partial seizures or Suicidal thoughts, depression, Monitor closely for
neuropathic pain. confusion, anxiety, diziness, and notable changes in
hostility behavior that could
indicate a the
emergence of suicidal
thoughts or depression.
Levothyroxine 88 mcg PO Daily Thyriod suplementation in HA, insomnia, irritability, Assess apica lpulse and
hypothyriodism. abdominal cramps, arryhtmias, BP prior to and
tachycardia, sweating, and periodically durring
meanstrual irregularities therapy.
Assess for tachycardia
and chest pain.
Losartan 50 mg PO BID Lowers BPand slowed Dizziness, anxiety, depression, Assess patient for signs
progression of diabetic fatigue, HA, hypotension, and of angioedema.
neuropathy. chest pain
Mirtazapine (Remeron) 15 mg PO Q bedtime Major depressive dissorder. Drowsiness, dizziness, Monitor closely for
constipation, dry mouth, changes in behavior that

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 hypotension, weight gain, could indicate the
suicidal thoughts, and emargence or
agranulocytosis worsening of suicidal
thoughtsor behavior or
depression.
Montelukast 10 mg PO Q evening Prevention of chronic treatment Suicidal thoughts, agitation, Monitor closely for
of asthma. anxiety, agression, hallucination, changes in behavior that
HA, insomina, tremor, could indicate the
weakness, and abdominal pain emergence of eorsening
depression or suicidal
thoughts.
Asssess for rash
periodically throughout
therapy because this
medication may cause
Stevens-Johnson
syndrome.
Potassium chloride 10 mEq PO Q evening Maintain acid-base balance, Confusion, restlessness, Monitor pulse, BP, and
isotonicity, and weakness, abdominal pain, ECG periodically
electrophysiologic balance of nausea, vomiting, and arrythmias during IV therapy.
the cell.
Pramipexole 0.5 mg PO BID Decreased treamor and rgidity Sleep attacks, amnesia, diziness, Assess patient for signs
in Parkinson’s disease. drowsiness, hallucinations, of psychotic like
weakness, abnormal dreams, and behavior and risk for
confusion these symptoms
increased with age.
Ropinirole 1 mg PO Q evening Management of signs and Sleep attacks, diziness, syncope, Assess patient for
symptoms of idiopathic agitation, confusion, delerium, drowsiness and sleep
Parkinson’s disease. delusion, and impulse control attacks. Drowsineess is
disorder a comon side effect
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)
Impaired physical mobility related to stroke as evidence by left sided hemiplegia.
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The goal is to improve the
patient mobility and prevent any
further injury.
Expected outcomes includes the
patient maintaining muscle
strength and joint ROM, patient
showing no further evidence of
complication, patient will
achieve highest level of
mobility.
Preforming ROM exercises to
joints unless contraindicatedat
least once every shift.
Identify the level of functioning
using a functional mobility scale.
Place items within reach of the
unaffected side of patient.
Preforming ROM exercises
prevents joint contractures.
Identifying the level of mobility
can establish a sense of
continuity in the patients care.
Palcing items within reach of
patients unaffected side
promotes the patients
independence.
Evaluate if the paitent met
the expected outcomes
includng maintaining muscle
strenght and evaluate if the
patient achieved the highest
level of mobility.

Secondary Nursing Diagnosis:

Risk for injury related to left sided hemiplagia.
The goal for this patient
includes identifying and
eliminating possible casues for
injury.
Expected outcomes for this
paitent include ackowledging
the prescence of envirionmental
hazards in their everyday
surroundings and patient and
family will develop a strategy to
maintain safety.
Improve envirionmental safetey
as needed including leaving bed
at lowest level, teach patient to
use call light, and raising side
rails when needed.
Help the patient and their family
identify situations and hazrds
that can casue accidents.
Provide additional patient
teaching as needed to include
household, automobile, and
pedestrian safety.
Improving safety will help Evaluate if the patient met the
patients cope with unfamiliar expected outcomes including
surroundings. acknowledging hazards and if
the patient developed a strategy
to maintain their safety.
Helping identifying hazards can
increase the patients awareness
to potential danger.
Providing additional teaching
helps the paitent take steps to
improve their safety.

Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socioeconomic
status, and 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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Reference:
Harding, M., Roberts, D., Reinisch, C., Haggler, D., Kwong, J. (2017). Lewis's Medical-Surgical Nursing. [Pageburstls]. Retrieved

from https://pageburstls.elsevier.com/#/books/9780323551496/

Phelps, L. (2017). Sparks and Taylor's nursing diagnosis reference manual (10th ed.). Hagerstown, MD: Lippincott, Williams &

Wilkins/Wolters Kluwer. ISBN-13: 9781496347817

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

Philadelphia, PA: F.A. Davis.