NURS 479 Care Plan

Student: Lizeth Hernandez Garcia Unit: CVICU Clinical Faculty: Paula Diamond

Pt Initials: PA Age: 79yrs Gender: Male Allergies: NKDA Code Status: Full Code

SECTION ONE: Background

(10 POINTS)
Date: Reason patient came to ED or hospital and chief complaints:

1-29- The patient came into the emergency room experiencing chest pain,
2022 elbow pain, as well as nausea. During his time in the ER, they completed
a series of labs such as a CBC, BMP, and a liver function test. They also
performed an ECG where the concluded the patient’s diagnosis.

Date: Admitting Diagnosis:

1-29- After several procedures, the patient was admitted to the hospital with a
2022 diagnosis of NSTEMI. The doctors later that night performed a left heart
catherization in which they discovered multivessel disease. The patient
was then put on heparin, a decrease dose of beta-blockers, and statins.
Their conclusion was that a CABG would be one of the greatest options
for this patient but due to his nonemergent condition, his surgery
should be scheduled.

Date: Why is your patient still hospitalized and what is the level of care
(M/S, ICU, Rehab, etc.)?
1-2-2022
The patient is still hospitalized and in the CVICU as he is post-op day
two with a CABG x 3 and needs frequent monitorization of his chest
tubes as well as his reaction to the surgery. We need to monitor that
there is no signs of bleeding or damage to the blood vessels.

Date(s): List all important past medical and surgical history:

1-29- According to the records, the patient had a medical history of

2022 dyslipidemia and Nonalcoholic Fatty Liver Disease (NAFLD). These
medical conditions are important to consider during his current
condition as both of these increase the mortality risk patients to suffer
an Acute Coronary Syndrome (ACS); in this case a NSTEMI (Ismaiel et al.,
2020).
 SECTION TWO: Pathophysiology
Must use, and correctly cite, two timely and credible sources. One source must
be your pathophysiology text.

(20 POINTS)
Disease Name: Myocardial Infarction: NSTEMI.

1. What causes this condition?

According to Capriotti (2020), a Myocardial Infarction (MI) is the result of the heart
tissue that suffers prolonged ischemia causing irreversible damage. An MI is
differentiated by two classes: ST Segment Elevation Myocardial Infarction (STEMI)
and Non-ST Segment Elevation Myocardial Infarction (NSTEMI). The main difference
between these two classes consists of STEMI indicating an infarction through all the
heart wall while NSTEMI indicates subendocardial damage (Capriotti, 2020).
Between these two classifications, it is considered that with a STEMI, an emergency
surgery should be done in order to save as much heart muscle as possible. If
classified with a NSTEMI, the patient is still at risk of going into STEMI but there is
much more heart tissue alive that provides oxygen to the rest of the heart. Some of
the factors that contribute to this particular disease consist of “atherosclerotic
plaque or clot and blocked blood carrying oxygen to the myocardium” (Capriotti,
p.378, 2020). In my patient’s case, the atherosclerotic plaque was partly formed due
to his past medical condition of NAFLD. According to Mayo Foundation (2021),
NAFLD is marked by liver inflammation and may progress to cirrhosis and liver
failure. When the liver is inflamed, the body accumulates excess lipids in vesicles
which in severe cases can rupture and have free radicals throughout the body.
When this happens, it increases the patient’s risk to form atherosclerosis
throughout their vessels (Capriotti, 2020). This can happen anywhere in the body
which in this patient’s cause, was his heart.

2. What is happening at the tissue or cellular level to cause this problem?

What is happening in the tissue and cellular level of this condition is that there is a
lack of blood flow to the subendocardial part of the heart, as well as a decrease of
oxygen supply (Capriotti, 2020). The heart later goes into hypoxia so myocardial
cells go into anaerobic metabolism and release lactic acid which in great amounts, is
harmful to the muscle cells. An extreme complication from this consists of all the
heart muscle may experience ischemia and hypoxia causing necrosis of myocardial
tissue. In my patient’s case, his heart is still going through some ischemia but only
in a small part of his heart. According to his cardiac catherization lab, 90% of his
left anterior descending artery was occluded and 60% of 1st and 3rd circumflex. This
means that his left lower part of the heart was going through ischemia causing the
release of lactic acid.
 3. What are the common s/s and clinical manifestations of this condition?
Underline the s/s that your patient has.

Although many patients suffering from NSTEMI may present with unique signs and
symptoms, the most common consist of chest pain that radiate to arms, jaw, and
back, diaphoresis, Levine’s sign, and weak pulses (Capriotti, 2020). Due to my
patient’s condition being a result of his NAFLD, his signs and symptoms consisted of
chest pain, elbow pain, and abdominal distention.

4. What are potential complications of this condition?

As mentioned before, one of the biggest complications of NSTEMI is heart attack.

When a muscle does not receive the adequate blood flow and oxygen supply, it may
cause irreversible damage which can later be seen as necrosis. Other potential
complications include dysrhythmias, papillary muscle rupture, pericarditis, and
heart failure (Capriotti, 2020). In my patient’s case, there were no extensive
complications as it was treated in a rapidly manner.

SECTION THREE: Diagnosis and Treatment

Must use and correctly cite two timely and credible sources. One source must
be your pathophysiology text.

(25 POINTS)
1. Labs or tests used to diagnose this condition. Which ones did your
patient get and what were the results? List all abnormal results.

Some of the labs and tests used to diagnose this condition consists of an ECG, blood
test specific to cardiac enzymes and proteins, check troponin 1 levels, as well as a
cardiac catherization lab to confirm it (Capriotti, 2020). Due to my patient’s
condition being a result from his NAFLD, some additional test that were done to
confirm the initial cause of his NSTEMI consisted of screening for liver infections
and liver function test (Mayo Foundation, 2021).

Lab Normal Value Patient Result

AST 10-40 u/L 76

ALT 7-56 u/L 83

HDL >40 39
 LDL <70 160

TRIGLYCERIDES <150 477

TROPONIN 1 0-0.4 7

Test: Results:

Cardiac Catherization Lab Left anterior descending artery 90% occluded,1st and 3rd
circumflex 60% occluded.

SECTION THREE: Diagnosis and Treatment (cont.)

2. Expected treatments or medications – Current best practice according to
literature (cited). Is your patient receiving this treatment(s)? Include
medications.

Treatments: Some of the treatments for this condition consists of initiating an

antiplatelet agent as soon as the chest pain starts as well as a
cardiac catherization lab to confirm and assess where the
obstruction is located (Capriotti, 2020). After a cath lab is done
and shows serious damages, a surgery is necessary to create a
new passage for blood flow into the heart and provide oxygen.
This surgery is best known as the Coronary Bypass Graft Surgery
(CABG). This procedure consists of getting a healthy blood vessel
from elsewhere and create bypass to the portion of the blocked
artery. In my patient’s case, everything mentioned above was done
including the CABG. He had a LIMA to his LAD and a RSVG to his
1st and 3rd CM’s. This just refers where a bypass was placed as
well as the procedure the surgeon accomplished.

Medications: Common medications that are given to treat this disease include
thrombolytic agents, anticoagulant medications, antiplatelet
medications, beta-adrenergic blockers agents, and calcium-
channel agonists. All these medications are important to give to
the patient in a timely manner in order to continue perfusing the
heart while also lower the oxygen needs of the heart. In my
patient’s case, when he got into the ED, he was given aspirin,
P2Y12, beta blockers, statins, heparin, and Lopressor. Once he
got out of surgery, he was still given statins and aspirin with an
addition of antibiotics and morphine for pain.
 SECTION FOUR: Plan of Care

(30 Points)
List Patient’s Top Five Priority Problems (in order of priority)
1. Ineffective breathing pattern.

2. Impaired mobility.

3. Risk for aspiration.

4. Acute pain.

5. Risk for infection.

Nursing Diagnosis for Problem # 1:

Ineffective breathing pattern related to inability to expand chest cavity as evidenced

by decreased SpO2% of 86%.

Measurable Goal for Problem # 1:

The patient will maintain an effective breathing pattern as evidenced by relaxed

breathing in normal rate and absence of apnea as well as an SpO2% above 90.

Priority Nursing Interventions to Meet Goal # 1:

Provide patient with oxygen per doctor’s orders with correct oxygen delivery method.

Assess/Monitor Therapeutic

1.Monitor patient’s SpO2% as well as 1. Encourage the use of incentive

breathing pattern.
2. Assess patient’s oxygen tolerance.
3. Assess patient’s ability to remove
secretions.
4. Monitor ABG’s for signs of hypoxia.
5. Assess the use of accessory muscles.
spirometer as well as deep breathing and
coughing.
2. Place patient in a sitting position to
increase ventilation.
3. Suction as needed to maintain a clear
airway.
4. Remain with patient during acute
episodes of respiratory distress.
 5. Encourage ambulation to break and
move secretions.

Nursing Diagnosis for Problem # 2:

Impaired physical mobility related to pain.

Measurable Goal for Problem # 2:

Patient will demonstrate increase mobility and have reduced pain by increasing the
length of his walks every shift before discharge.

Priority Nursing Interventions to Meet Goal # 2:

Assist patient with physical mobility per doctors order each shift.

Assess/Monitor Therapeutic

1. Evaluate the need for assistive 1. Promote ambulation each shift with
devices. assistive device.

2. Monitor patient’s vital signs before, 2. Set goals with patient.

during, and after walking.
3. Let patient accomplish goal at his own
3. Assess for a safety environment. pace

4. Assess patient tolerance on physical 4. Give medications appropriately to

mobility. reduce pain.

5. Monitor nutritional needs. 5.Provide patient with rest periods in

between activities.

SECTION FIVE: Integrative Therapy, Education, and Referrals

(10 Points)
Describe the Integrative Nursing Modality used on your patient and why this
therapy was selected:

An integrative nursing modality I used with my patient was deep breathing. As our
shift initiated with his chest tubes being remove, his breathing pattern started to be
abnormal and was also showing signs of dyspnea. At this current time, the patient
was already in 5Lts of oxygen in a nasal cannula through his mouth as he was a
mouth breather. This is when I initiated the deep breathing technique with him in
order to show him how he had to properly breath for the oxygen to work. Due to the
language barrier, I was doing the deep breathing with him so we could
simultaneously perform it and be able to assess if it was helping the patient. After
some deep breaths, his oxygenation was in the 90’s which was what the doctor
ordered. The problem here was that his oxygenation would decrease when not doing
the deep breaths. My nurse and I decided to change him to a venti mask 50% with
12 liters of oxygen and continue to demonstrate the deep breathing technique. This
is when his oxygenation maintained in the lower 90’s and his breathing pattern
started to get normal. I chose this integrative modality even though the patient was
already receiving oxygen as I it can be difficult and strange to be receiving high flows
of oxygen when they are used to breath in normal air. I believe what it is important
to understand in these situations is that even though oxygen might help the patient,
we still have to educate and demonstrate what to properly do when being in oxygen
therapy.

List two educational interventions you completed with your patient:

1. An educational intervention I completed with this patient was the chest tube
removal procedure and what he should expect from it. With the help of the
translator, my nurse and I were able to demonstrate as well as communicate to him
how the removal procedure would go and what we wanted him to do. During this
time, we also asked him if he was experiencing any pain so we could give him
something before we started the procedure.

2. Another educational intervention I completed with my patient was the sternal

precautions. Due to his recent surgery, the patient could not use his hands to give
himself support as it could increase the chances of his surgical incision to open. At
the beginning of the shift, me and my nurse explained the precautions he had to
take as well as how to use the pillow when sitting him up. He verbalized his
understanding to the translator, so we continued with his care. Throughout the
shift, he would not follow these precautions so I would often have to demonstrate
and signal him how he could not use his arms for support, but rather the pillow. He
would nod in acceptance and would immediately hug the pillow showing us his
understanding of the precautions he had to take.

List required referrals to two allied health services:

1. A required referral I believe would benefit the patient would be with a

pulmonologist and speech therapist. Due to his recent decrease in oxygenation and
abnormal breathing pattern, I would suggest having his chest be evaluated to see if
the chest tubes could have caused any damage or if the patient is just adjusting to
breathing without them. In this consultation I would include speech therapist as I
would also like to know whether the patient is having any difficulties through his
oral passage.
 2. Another referral I would suggest for this patient would be physical therapist as
well as an occupational therapist consultation. Due to his recent open-heart
surgery, the patient will have to adapt to the sternal precautions in order to let his
chest recover properly. With the physical therapist, he could learn how to properly
take care of himself as well as continue with his mobility and become independent
each day. With the occupational therapist, it will help the patient adapt to his new
lifestyle as he will have changes in his diet and overall lifestyle. What the
occupational therapist will do for the patient is help with his emotional, social, and
physical needs before he is discharge of the hospital.

SECTION SIX: APA 7th ed. References

(5 Points)

Capriotti, T. M. (2020). Pathophysiology introductory concepts and clinical perspectives (2nd

Edition). F. A. davis company. https://bookshelf.vitalsource.com/books/9781719642491.

Ismaiel, A., Popa, S. L., & Dumitrascu, D. L. (2020). Acute coronary syndromes and
nonalcoholic fatty liver disease: "Un affaire de coeur". Canadian journal of
gastroenterology & hepatology, 2020, 8825615. https://doi.org/10.1155/2020/8825615.

Mayo foundation for medical education and research. (2021). Liver function tests. Mayo clinic.
https://www.mayoclinic.org/tests-procedures/liver-function-tests/about/pac-20394595.

Mayo foundation for medical education and research. (2021). Nonalcoholic fatty liver disease.
Mayo clinic. https://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-
disease/symptoms-causes/syc-20354567.