Care Plan

Student: Alexandria Casarez Date: 3/7/21

Course: NSG-444 Instructor: Lourdes Posthast

Clincial Site: St Josephs Hospital Client Identifier: RS Age: 47

Reason for Admission: Patient was admitted to the hospital originally on 11/20/20 dut to a SARS-Cov-2 infection (COVID).

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

Patients current medical diagnosis includes pneumonia related to Clinical manifestations for pneumonia can include
COVID infection. The pathophisiology related to pneumonia is coughing, fever, chills, dyspnea, tacypnea, and pleural chest
related to the pathogen that is causing the pnuemonia. The pain(Lewis et al., 2017). For the patient in discussion some
pathogen leads to an inflamatory response in the lungs. Leading to clinical manifestations that were present included shortness
increased bloodflow, vascular permeability, and activates of breath and fatigue.
neutrophils to kill the pathogen. Due to the inflamatory response
edema occurs and fluid leaks from the capillaries and
compromizes oxygen transporatation. Risk factors inlcude
abdominal or chest surgeries, altered level of consciousness,
bedrest or prolonged immobility, chronic disease,
immunosupressive therapies, and malnutrions (Lewis, Bucher,
Heitkemper, Harding, Kwong & Roberts, 2017).

Assessment Data
Subjective Data: Patient appears to be improving from previous status. Patients states that he is “doing ok this morning”. Patient shares
anxiety with the nurse about titrating down his oxygen concentrations despite having adequate saturations on the monitor. Patient shared that
© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18
they still need 12L of oxygen while transfering from bed to the chair and can tolerate 10L while at rest. Patient also stated that he is most
comfortable in the bed but will allow for time in the chair thorughout the day.
VS: T : 36.7 C Labs: Diagnostics:
BP: 110/62 Labs were drawn on 3/5 the following include -Chest x-ray on 3/1/21
labs that were outside the normal ranges.
HR: 83 -multifocal interstitial opacities and pulmonary
RR: 22 -RBC (4.27-5.73)- 2.50 (L) pts low count could scarring
be realted to nutritional defeciency and
O2 Sat: 95% on 10L - Nasal swab for SARS-Cov-2
decreased activity
HFNC -positive initailly on 12/17 and most recently on 3/5
-HGB (12.9-16.1)- 7.5 low HGB could be related
T : 36 C to medications with side effects of anemia
BP: 115/68 -HCT (37.7-51.3)- 22.7 (L) related to side effects
HR: 78 from medication leading to anemia

RR: 22 RDW (11.5-14.5)- 17.1 (H) possible due to

nurtitional defficiencies
O2 Sat: 97% on 10L
HFNC Neutrophils (35-75)- 87 (H) related to pulmonary
infection
Lymphocytes (0.6-4.8)- 0.3 (L) related to
pulmonary infection

Assessment: Orders:
Neurological: alert and oriented x 4, awake, clear speech; brisk pupils, -DNR codes status
both pupils are 4mm; they open spontaneously; all extremities (both -Continuous pulse oximerty reading
sides of upper and lower) are equal, and moderately strong, patient
-Activity as tolerated
presents with mild tremors in all extremities.
Respiratory: diminished breath sounds bilaterally in right and left lungs -Up to chair for meals
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with crackles auscultated in the upper lobes; unlabored breathing with -Anticoagulation education
dyspnea upon transfering form bed to chair; no cough present; no -Aspiration preautions
sputum; oxygen saturation is at 95% on 10L of the HFNC
-Blood glucose monitoring AC/HS
Cardiac: heart rate of 84 is strong and WNL with no ectopic sounds; S1
and S2 sounds noted; no edema present; JVD not present; tele -Cardiac monitoring
monitoring: normal sinus rhythm. -Isolation for droplet and contact precautions
Vascular: pulses are 3+ in radial and dorsalis pedis, no doppler needed;
cap refill is < 3 seconds. -VTE education
Gastrointestinal: abdomen is flat and equal in size; bowel sounds are -Implementation of VTE prevention
WNL; last bowel movement at 1700, soft, and small in quantity; no
tenderness; patient is on a regular diet with a good apetite.
Genitourinary: voids; using urinal while in bed or in the chair.
Hygiene: patients complete hygine in the AM with the PCT .
Mobility: fall risk, patient does not ambulate, and must be transferred to
chair or bed. Patient has full range of motion in arms and can pull
himself up in bed but less function of the lower extremities.
Skin: appropriate skin color for ethnicity; patients has a small pressure
ulcer on the right sacral area, skin is still intact and has nonblanchable
redness.

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 Medications
ALLERGIES: No known drug allergies

Name Dose Route Frequency ndication/Therapeutic Effect Adverse Effects Nursing

Considerations
Absorbic acid (vitamin 500 mg PO Daily -increase levels related to a deficency Nausea, vomiting, Monitor the patinent
C) heartburn, stomach cramps for adverse side effects
and headache or signs of allergic
reactin to the
medication after
administration.
Azithromycin 250 mg PO Q MWF -treatment of upper and lower respiratory Dizziness, drowsiness, Assess patients for
tract infections fatigue, headache, chest infection before and
pain, torsades de pointes, throughout therapy.
chest pain, hypotension, Monitor patient for
palpitaions, stevens-johnson signs and symptoms of
syndrome, ototoxicity, anaphylaxis reaction
hyperkalemia, to the medication.
hepatotoxicity, anemia
Enoxaparin 40mg SQ Daily Used for the prevention of a thrombus Dizziness, insomnia, edema, Assess for signs of
formation. increased liver enzymes, bleeding or bruising,
urinary retention, rash, check platelet count
bleeding, anemia, and APTT and PT
hematoma, and fever, etc. levels, monitor for
hypersensitivity,
hepatic/renal disease,
and untreated
hypertension.
Escitalopram 10mg PO Q Day Used for antidepressant action. Suicidal thoughts, seratonin Asses patient for
syndrom, and diarrhea suicidal tendencies,
and monitor for mood
changes and level of
anxiety.
Gabapentin 300 mg PO Q HS Used for partial seizures or neuropathic Suicidal thoughts, Monitor closely for
routine pain. depression, confusion, notable changes in

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 anxiety, diziness, and behavior that could
hostility indicate a the
emergence of suicidal
thoughts or
depression.
Insulin Glargine 5 units Sub Q Q AM Control of hyperglycemia in patients with Hypoglycemia, puritis, Assess for symptoms
type 1 and type 2 diabetes mellitus. erythemia, swelling, of hypoglycemia
anaphylaxis (anxiety; restlessness;
tingling in hands, feet,
lips, or tongue; chills;
cold sweats;
confusion; cool, pale
skin; difficulty in
concentration;
drowsiness;
nightmares or trouble
sleeping; excessive
hunger; headache;
irritability; nausea;
nervousness;
tachycardia; tremor;
weakness)and
hyperglycemia
(confusion,
drowsiness; flushed,
dry skin; fruit-like
breath odor; rapid,
deep breathing,
polyuria; loss of
appetite; unusual
thirst) periodically
during therapy.

Melatonin 5 mg PO Q HS Hormone that aids in regulating the sleep Hypotension, drowsiness, Assess the patients
wake cycle and promote sleep. headache, dizziness, nausea, sleep paterns proir to
vomiting, stomach cramps, and throughout
therapy to determine if
desired effect is being
achieved.

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 12.5 mg PO BID Used to treat hypertension unlabled use to Fatigue, weakness, anxiety, Monitor the paitents
Metoprolol treat tremmors. depression, dizzines, ECG, BP, and vital
drowsiness, bradycaria, and signs, throughout
erectile dysfunction therapy.
Monitor the paitents
intake and output and
dialy weights to
determine if the
patient is having fluid
imbalances.
Multivitamin 1 tab PO Daily Treatment of vitamin defficiency. Diarrhea, constipation, or Recommend patient
upset stomach. takes after food if
causing an upset
stomach.

Mycophenalate mofetl 250 mg PO BID Prevention of rejection in allogenic organ Anxiety, dizziness, Monitor stools for
transplant. headache, insomnia, signs and symptoms of
tremors, parasthesia, edema, GI bleeding including
hypertenion, hypotension, bloody stools or dark
tachycardia, anorexia, tarry colored stools.
anemia, nausea, and Assess for signs and
vomiting symtoms of an
infection which can
include fever,
weakness, weight loss,
diziness, faitness,
dyspnea, and loss of
appetite
Pantroprazole 40 mg PO Q Daily Decrease relapse rates of daytime and Headache, abdominal pain, Assess patient
nighttime heartburn symptoms on patients diarrhea, flatulents, routinely for epigastric
with GERD. hyperglycemia, and or abdominal pain and
hypomagnesemia for frank or occult
blood in stool, emesis,
or gastric aspirate.

Posaconazole 300 mg PO Q Daily Prevention of Diarrhea, nausea, vomiting, Monitor for signs of
invasive Aspergillus and Candida infection and adrenal insufficiencies an alergic reaction
s in severely immunocompromised patients including resporatory

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 distress.
Monitor for signs of
an adrenal
insufficency which
include hypotension,
weight loss, weakness,
nausea, vomiting,
lethergy, consusion,
and restlessness.
Prednisone 250 mg PO Q Daily Used systemically to reduce inflamation Depresssion, euphoria, Monitor patients for
headache, hypertension, signs and symptoms of
nausea, vomiting, acne, thrombophlebitis and
decreased wound healing, thromboembolism that
muscle wasting, increase can be caused by this
susceptability to infection medication.
Sulfamethoxazole- 1 tab PO Q MWF Used as an anti-infective Fatigue, halucinations, Monitor for signs and
trimethoprim headache, insomnia, symptoms of allergic
depression, nausea, reaction or respiratory
vominting, rash, fever, and distress.
stevens-johnson syndrome Monitor for signs and
(Vallerand, Sanoski & symtoms of Stevens-
Deglin, 2017) used for all johnsons syndrome
medication adverse effect which can include
references. rash, blister, and flu
like symtoms.
(Vallerand, Sanoski &
Deglin, 2017) used for
all medication nursing
consideration
references.
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 gas exchange related to pulmonary inflammation secondary to coved pneumonia as evidence by low oxygen
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saturation of 95% and high administration of supplemental oxygen.
The goal for this patient is to
reduce dependency on
supplemental oxygen while
keeping an adequate oximetry
reading.
Secondary Nursing Diagnosis:
Impaired physical mobility related to musculoskeletal impairment.
The goal for this patient is to
increase the level of mobility
and level of tolerance to
activity.
The expected outcone for this
patient is to reduce the
ammount of oxygen from 10L,
as tolerated by the patient (as
well as the patients oxygen
saturation remaining abover
95%) by the end of the shift.
The expected outcome for this
paitent includes maintaining
muscle strength and joint range
of motion, and will achive the
highest level of mobility by the
patients discharge
1. Encourage patients to 1. Encouraging period of
alternate periods of rest rest is important
and activity. because activity
2. Auscultate lungs every 4 increases tissue oxygen
hours and report consumptions and rest
abnormalities. enhances tissue oxygen
3. Monitor patients vital perfusion.
signs, heart rhythm, and 2. Auscultating lungs
arterial blood gasses. allows for detection of
decreased or
adventitous breath
sounds.
3. Monitoring vital signs
allows for the nurse to
detect impaired gas
exchange [(Phelps,
Ralph & Taylor, 2017)
used for all rationale
references].
1. Preform ROM 1. Preforming excercises
excercises to joints at prevents joint
least once every shift. contractures from
Progress from passive forming and muscular
to active as tolerated. atrophy.
2. Encourage 2. Encouraging the
independence in patients to use side
mobility by helping the rails increases the
to use side rails and/or muscle tone and the
trapeze to preform self patients self esteem.
care activities. 3. Placing objects within
3. Place personal items reach promotes patient
within reach of the independence [(Phelps,
patient when leaving Ralph & Taylor, 2017)
the room. used for all rationale
references]. and
1. Met: patients spent
time resting between
periods of moving
throughout the shift
2. Met: lungs were
ausculated every 4
hours
3. Met: the patients
vital signs were
monitored by the
nurse and the CNA
throughout the shift
1. Met; physical therapist
aided the patient with
ROM excercises
durring the shift
2. Met; patient used the
side rails of bed
durring a transfer from
bed to chair to adjust
themselves in the bed
as desired
3. Met; when leaving the
patients room patients
bedside table, phone,
call light, and urinal
were placed within
reach.
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 encourages activity
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
Lewis, S. L, Bucher, L., Heitkemper, M. M., Harding, M. M, Kwong, J., & Roberts, D. (2017). Medical-surgical nursing: Assessment
and management of clinical problems (10th ed.). St. Louis, MO: Elsevier. ISBN-13: 9780323328524
Phelps, L., Ralph, S., & Taylor, C. (2017). Sparks & Taylor’s Nursing Diagnosis Reference Manual (10th ed.). Riverwood, IL: Wolters
Kluwer. ISBN: 9781496347817
Vallerand, A., Sanoski, C., & Deglin, J. (2017). Davis’s Drug Guide for Nurses (15th ed.). Philadelphia, PA: F. A. Davis Company.
ISBN: 9780803657052