PRAIRIE VIEW A&M UNIVERSITY
COLLEGE OF NURSING
ASSESSMENT AND PLANNING GUIDE FOR USE IN THE HOSPITAL
The following information should be included daily as it applies to your patient.
Demographic Data
G.C is a 67-year-old Hispanic female
Height: 5’0
Weight: 121lbs 4.1 oz
Date of Admission
04/07/2022
Vital Signs (D1) (D2)
Day 1
Day 2
Significant Past Medical History
 Renal cyst (11/09/2016)
 Peripheral Arterial Disease (02/21/2013)
 Hyperlipidemia (05/27/2010)
 Osteoarthritis (05/27/2010)
 Diverticulosis (11/09/2016)
 Femoral-popliteal bypass (06/2013)
 Tubal ligation
 Foot surgery
Pulse: 82 bpm
RR: 12 bpm
BP: 131/66 mmHg
MAP: 87 mmHg
Sp02: 95% on RA
Temp: 99 F
Pulse:
RR:
BP:
MAP:
Sp02:
Temp:
Allergies/Reactions





Dexilant (diarrhea)
Pneumovax 23 (nausea
and vomiting)
Gabapentin (palpitations)
Eggs (No known reaction)
Lactose intolerance
(nausea and vomiting)
Reason for Hospitalization and Current Diagnosis
Patient came in with RLE claudication and occlusion of right femoropopliteal bypass graft. She
also had limb ischemia s/p femoral-popliteal bypass surgery and vitamin b-12 deficiency. As
well as presenting with GERD w/o esophagitis. She is also in acute renal failure stage.
Describe the pathophysiology including signs, symptoms and incidence; and compare with
patient findings:
Peripheral Arterial Disease

Patho/ Causes: is a common circulatory problem in which narrowed arteries reduce
blood flow to your limbs and is commonly caused by atherosclerosis. The patient
has prior history of hyperlipidemia, and she has hypertension which are major risk
factors for atherosclerosis leading to PAD.

Signs and Symptoms: includes painful cramping in one or both of your hips,
thighs or calf muscles after certain activities, such as walking or climbing stairs
(claudication), leg numbness or weakness, coldness in your lower leg or foot,
especially when compared with the other side, sores on your toes, feet or legs that
won't heal, a change in the color of your legs, hair loss or slower hair growth on
your feet and legs, slower growth of your toenails, shiny skin on your legs, no pulse
or a weak pulse in your legs or feet, erectile dysfunction in men, pain when using
your arms, such as aching and cramping when knitting, writing or doing other
manual tasks. My patient presented with claudication in her right leg and had weak
pedal pulse in her right leg. She also had capillary refill of more than 3 secs in the
right leg and had tissue ischemia around that leg which was brown.



Complications: includes limb ischemia, stroke, and heart attack. My patient came
in with ischemia on right lower leg which indicates a complication of PAD which
has not been manage correctly.
Diagnostic Labs: includes physical exam, Ankle-brachial index, ultrasound,
angiography, and blood test. The patient had a blood test done as well as
angiography was performed and physical exam which was found that the patient
ischemia.
Treatment: includes cholesterol-lowering medications, antihypertensives
medications, medications to control blood sugar if that is the cause, blood thinners
(anticoagulants) and symptom relief drugs. As well as Angioplasty, bypass
surgery, and thrombolytic therapy. My patient’s treatment consists of
atorvastatin, heparin, lisinopril, alteplase which are drugs used in treating PAD
and accompanying symptoms. She also underwent bypass surgery and
angioplasty as well to help resolve the problem.
Medication
Drug/Dose
Acetaminophen
(1000 mg oral q6h)
Classification/Action
Thought to produce analgesia by
inhibiting prostaglandin and other
substances that sensitize pain
receptors. Drug may
relieve fever through central
action in the hypothalamic heatregulating center. (Analgesics)
Purpose for use in this patient
To relieve pain and high temp for the
patient.
Alteplase (20 mg in
sodium chloride 1
mg/hr continuous)
Atorvastatin (20 mg
oral @bedtime)
Converts plasminogen to plasmin
by directly cleaving peptide
bonds at two sites, causing
fibrinolysis.
(Thrombolytics)
Inhibits HMG-CoA reductase, an early
(and rate-limiting) step in cholesterol
biosynthesis. (Antilipemic)
To resolve the clots that is in her leg.
To control high cholesterol levels
Bisacodyl (10 mg rectal
once)
Stimulant laxative that increases
peristalsis, probably by direct
effect on smooth muscle of the
intestine, by irritating the muscle
or stimulating the colonic
intramural plexus. Drug also
promotes fluid accumulation in
colon and small intestine.
(Laxatives)
To make her stool softer and easier
for the stool to pass through the
rectum and to prevent hemorrhoids
since patient is at high risk for
bleeding.
Cyanocobalamin (1000
mcg oral daily)
Heparin (1000 units
injection continuous;
25,000 units 15
units/kg/hr intravenous)
Prevent and treats low blood levels
of vitamin B12. (Vitamins)
To increase her vitamin B12 levels
Accelerates formation of
antithrombin III–thrombin
complex and deactivates
thrombin, preventing conversion
of fibrinogen to fibrin.
(Anticoagulants)
To dissolve clots that may be present
in her legs
Lidocaine 5% ( 2
patch)
Topical lidocaine stabilizes the
neuronal membrane by inhibiting
the ionic fluxes required for the
initiation and conduction of
impulses, thereby effecting local
anesthetic action. (Analgesics)
To help relieve any pain after her
procedures
Lisinopril (10 mg oral
BID)
Causes decreased production
of angiotensin II and suppression
of the RAAS. (Antihypertensives)
To help decrease and or regulate her
blood pressure to normal levels.
Melatonin (5 mg oral
@ bedtime)
regulates the sleep-wake cycle by
chemically causing drowsiness
and lowering the body
temperature. (Sedative)
To help her sleep at night
Methocarbamol (1,125
mg oral q8h)
Action not established. Drug is a
CNS depressant. It has no direct
action on the contractile
mechanism of striated muscle, the
motor end plate, or the nerve
fiber. (Muscle Relaxants)
To help with RLE claudication and
to relieve muscle stiffness or rigidity
hence the patient has osteoporosis
and osteoarthritis.
Ondansetron (4 mg IV
push q6h)
May block 5-HT3 in the CNS in
the chemoreceptor trigger zone
and in the peripheral nervous
system on nerve terminals of the
vagus nerve. (Antiemetics)
Helps relieve any nausea or vomiting
patient may have.
Polyethylene glycol (17
g oral 2 times daily)
Causes water to be retained in
stool. (Laxatives)
Pregabalin (50 mg oral
BID)
May contribute to analgesic and
anticonvulsant effects by binding
to sites in CNS. (Anticonvulsants)
To make her stool softer and easier
for the stool to pass through the
rectum and to prevent hemorrhoids
since patient is at high risk for
bleeding.
To prevent seizures
Sennosides-docusate
sodium 8.6-50mg (2
tablet oral BID)
Stool softener that reduces
surface tension of interfacing
liquid contents of the bowel. This
detergent activity promotes
incorporation of additional liquid
into stools, thus forming a softer
mass. (Laxatives)
To make her stool softer and easier
for the stool to pass through the
rectum and to prevent hemorrhoids
since patient is at high risk for
bleeding.
Tramadol (100 mg oral
q8h)
Unknown. Thought to bind to
opioid receptors and inhibit
reuptake of norepinephrine and
serotonin. (Analgesics)
To help relieve pain
Intake/Output
Diet__NPO_____
Enteral Feeding_NPO____ Drainage/Tubes__320 mL______
Intravenous Fluids/Flow/Rate:
Alteplase 1 mg/hr
Heparin 60 mL/hr
Heparin 15 units/kg/hr
Procedures/Surgery: (Describe).
 TPA: TPA is a naturally occurring protein found on endothelial cells, the cells that line


blood vessels. It activates the conversion of plasminogen to plasmin, an enzyme
responsible for the breakdown of clots, helping restore blood flow to the brain
Angioplasty: is a procedure used to open blocked coronary arteries caused by coronary
artery disease. It restores blood flow to the heart muscle without open-heart surgery.
Pedal arterial access w/sheath left in place: used to gain arterial access and facilitate the
insertion of catheters or other equipment for diagnostic and vascular interventions.

Retrograde RLE angiogram through pedal access: allow the treatment of tibial occlusive
lesions when standard endovascular techniques fail.
Oxygen Therapy
Room air
Ventilator Setting:(if applicable)
N/A
Other Equipment/Lines applicable (eg PA catheters, A-lines, etc)



Right tibial venous access sheath
Urinary catheter
Double lumen arterial sheath
Diagnostic Studies/Lab Data
(Identify abnormalities and describe their significance in the patient).
RBC (4.20-5.40) - 2.48
Related to patient blood loss during the TPA procedure
Hgb (12.0-16.0) – 6.5
Related to patient blood loss during the TPA procedure
HCT (37.0-47.0) – 20.4
Related to patient blood loss during the TPA procedure
MCH (27.0-32.0) – 26.2
Related to patient blood loss during the TPA procedure
MCHC (32.0-36.0) – 31.9
Related to patient blood loss during the TPA procedure
Platelets (150-400) – 97
Related to PAD makes it difficult for the patient to coagulation abilities and as well as blood loss
PT (11.7-14.5/ 23.9-36.0)
Due to the thrombolytic therapy
INR – 2.9
Due to the thrombolytic therapy
PTT- 60.0 secs
Due to the thrombolytic therapy
Treatments
(Provide rational for use)
Thrombolytic therapy (TPA, Heparin, Alteplase)- to help dissolve the blood clot in her leg
Blood products- to help with blood less and anemia
Antihypertensive (lisinopril)- to help manage her high blood pressure to prevent further
complications
Lipidemic (atorvastatin) - You may take a cholesterol-lowering drug called a statin to reduce your
risk of heart attack and stroke
Angioplasty of venous graft- reopen the artery while stretching the artery open to increase blood
flow.
Response to Illness and Hospitalization
Patient’s anemia has not been corrected based on recent lab results. Patient is responding to
thrombolytic therapy which has dissolve the clot. Patient has no questions or concerns
regarding hospitalization. She says her nurse is doing a great job keeping her up to date with all
procedures and medical information.
Physical Assessment findings (ROS)
General appearance: clean, has long black hair and wearing hospital scrubs.
Neuro: Alert and orientated x 4
Resp: Clear breath sounds bilaterally
Cardiovas: Regular S1 and S2 sounds heard, and flat jugular vein and normal sinus rhythm.
GI: present bowel sounds in all four quadrants
GU: patient has a urinary catheter in and has 320 mL output
Muscul: patient has full ROM, but its muscle strength diminishes and lower legs
Integumentary: skin is warm to touch, bruising around right knee, and brown discoloration of
skin around the right lower leg.
Other:
Discharge Plans
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Educate patient regarding medication adherence pertaining to antihypertensives and
lipidemic to help manage preexisting condition of hypertension and hyperlipidemia.
Inform patient about the importance of keeping the bypass graft site sterile
Inform the patient on signs and symptoms of thrombosis and decreased tissue perfusion
so patient can immediately call 911 and notify her physician
Inform patient regarding signs and symptoms of stroke or heart attack and if so to call
911
Educate patient on the importance to ambulating as tolerated to prevent further skin
breakdown
Teaching and Health Promotion Needs
Knowledge Based
Nursing Diagnosis
Knowledge deficit r/t
peripheral arterial
disease management
AMB:
1.) Patient
developed
ischemia
of right
lower leg
Goals & Objectives
Content
By 03/14/2022 patient
will verbalize
understanding of selfcare measures
required to treat and
further prevent
complications AEB:
1.) Patient will
prevent further
ischemia of the
leg by
ambulating a
little and use of
compression
stockings
1) Instruct patient on further
prevention of
complications:
a) Wear compression
stockings to bed at
night or as needed
b) Hypertension
management
c) Lipid management
d) Ambulate as
tolerated daily
2) Provide a brochure on foot
care
3) Provide a video that
explains importance of
ambulating and managing
preexisting health
conditions.
4) Have patient repeat back
key points of our
discussion to demonstrate
understanding.
Nursing Diagnoses
(List top 7 in order of priority)
Method
1.) One on One
discussion
2.) Brochure
3.) Video
4.) Teach back
Evaluation
1. Impaired peripheral tissue perfusion r/t blood clot in right lower leg AMB: patient’s right lower leg is becoming ischemic,
patient’s Hgb levels is 6.5, patient’s HCT levels is 20.4, patient’s RBC is 2.48, and patient had weak pedal pulse in right
lower leg, patient had low air loss bed in right foot.
2. Impaired tissue integrity r/t decreased peripheral tissue perfusion AMB: patient’s bruising of right knee, and patient had
brown discoloration to the right lower leg.
3. Impaired physical mobility r/t musculoskeletal impairment AMB: patient has muscle wasting due to age, patient is lactose
intolerant which explains low calcium and vitamin B12 levels, patient also was diagnosed with osteoarthritis, patient has
claudication of right lower leg.
4. Ineffective health management r/t complexity of therapeutic regimen AMB: deterioration of peripheral perfusion in lower
extremities, patient has ischemic tissue on right lower leg, patient has difficulty ambulating, patient develops a reocculsion
of right femoropopliteal bypass graft, and patient has claudication.
5. Risk for infection
6. Risk for bleeding
7. Risk for falls
Nursing Care Plan
(Formulate nursing care plan on 3 of nursing problems (diagnoses) listed, Use nursing care plan forms)
Nursing Diagnoses
Nursing Diagnosis
Human Response R/T
Etiology
Goals/
Outcome Criteria
Interventions
Specific & Individualized
Rationales
with references
Evaluation
Did the patient achieve the
goal?
Impaired peripheral
tissue perfusion r/t
blood clot in right
lower leg AEB:
1.) patient’s right
lower leg is
becoming
ischemic
2.) patient’s Hgb
levels are 6.5
3.) patient’s HCT
levels is 20.4
4.) patient’s RBC
is 2.48
5.) patient had
weak pedal
pulse in right
leg
6.) patient had
capillary refill
was more than
3 seconds in
right foot.
By 03/14/2022 patient
will maintain optimal
peripheral tissue
perfusion AMB:
1.) patient’s right leg
will not have
further ischemic
of tissue.
2.) Patient’s Hgb
levels will be
more than 12.0
3.) Patient’s HCT
levels will be
equal to or more
than 37.0
4.) Patient’s RBC
levels will be
equal to or more
than 4.20
5.) Patient will have
strong pedal pulse
in the right leg
6.) Patient’s capillary
refill will be less
than 3 seconds in
right foot.
1.) Assess vital
signs q4h
2.) Assess for signs
of decreased
tissue perfusion
3.) Monitor Hgb
levels
4.) Administer
alteplase 20 mg
in sodium
chloride 1
mg/hr intraarterial
continuous as
ordered by
physician
5.) Administer
Heparin 1,000
units in 0.9%
NaCl 500 mL
60 mL/hr
injection
continuous as
ordered by
physician
6.) Administer
lisinopril 10 mg
oral Bid as
ordered by
physician
7.) Educate and
instruct patient
to inform nurse
1.) Vital signs provide baseline
data (Gulanick, pg. 141,
2022)
2.) Specific clusters of signs and
symptoms as listed in the
supporting data are general
indications of adequacy of
tissue perfusion. Evaluation
provides a baseline for future
comparisons. Arterial
thrombus at the puncture site
may lead to occlusion of the
artery or distal thrombosis in
the extremity (Gulanick, pg.
142, 2022)
3.) Low levels reduce the uptake
of oxygen at the alveolarcapillary membrane and
reduce oxygen delivery to
the tissues (Gulanick,
pg.142, 2022)
4.) Used to reduce blood
viscosity and coagulation
(Gulanick, pg.143, 2022)
5.) Used to reduce blood
viscosity and coagulation
(Gulanick, pg.143, 2022)
6.) Used to reduce systemic
vascular resistance and
optimize cardiac output and
perfusion (Gulanick, pg. 143,
2022)
7.) Early assessment facilitates
of any signs of
decreased tissue
perfusion.
prompt treatment (Gulanick,
pg.144, 2022)
Nursing Diagnoses
Nursing Diagnosis
Human Response R/T
Etiology
Impaired tissue
integrity r/t decreased
Goals/
Outcome Criteria
By 03/14/2022
patient’s remaining
skin will be intact
Specific & Individualized
Interventions
Rationales
with references
1.) Assess vital
signs q4h
2.) Assess the
1.) Vital signs provide baseline data
(Gulanick, pg. 140, 2022)
2.) These data provide information on
Evaluation
Did the patient achieve the
goal?
peripheral tissue
perfusion AMB:
1.) patient’s
bruising of
right knee
2.) patient had
brown
discoloration
to the right
lower leg.
without signs of
injury, redness, or
infection AEB:
1.) Patient’s
bruise will
decrease in
size.
2.) Patient skin
surrounding
the ischemic
tissue will
remain free
from
discoloration.
characteristics
of the wound
(color, size,
odor, and
drainage)
3.) Provide tissue
care as
ordered by
physician
4.) Protect the
skin from
trauma and
prolonged
pressure
5.) Encourage a
diet that meets
nutritional
needs
extent of damage. Pale tissue color is
an indication of decreased
oxygenation. Odor may arise from
infection present in the wound; it may
also arise from necrotic tissue. Serous
exudate from a wound is a normal part
of inflammation and must be
differentiated from pus or purulent
drainage, which is an indication of
infection (Gulanick, pg.140, 2022)
3.) Each type of wound is best treated
based on its etiology. For example,
skin wounds may be covered with wet
or dry dressings, topical creams or
lubricants, hydrocolloid dressings
(e.g., DuoDerm) or vapor-permeable
membrane dressings such as
Tegaderm. An eye patch or hard,
plastic shield may be worn for a
corneal injury. The dressing replaces
the protective function of the injured
tissue during the healing process
(Gulanick, pg. 140, 2022)
4.) The poor peripheral circulation of
PAD combined with deceased
sensation places the patient at high
risk for injury. Attention to this
nursing action minimizes the risk of
harm to the patient (Gulanick, pg. 358,
2022)
5.) A high-protein, high-calorie diet may
be needed to promote healing
(Gulanick, pg. 141, 2022)
Nursing Diagnoses
Nursing Diagnosis
Human Response R/T
Etiology
Impaired physical
mobility r/t muscle
strength AMB:
Goals/
Outcome Criteria
By 03/14/2022, patient
will demonstrate use of
adaptive techniques that
Interventions
Specific & Individualized
1.) Assess vital
signs q4h
2.) Assess ROM of
Rationales
with references
1.) Vital signs provide baseline
data (Gulanick, pg. 141,
2022)
Evaluation
Did the patient achieve
the goal?
1.) patient has
promote ambulation and
muscle loss transferring AEB:
due to age
1.) patient will seek
2.) patient is
physical therapy
lactose
to help build
intolerant
muscle strength
which
explains low
2.) patient will take
calcium and
supplemental
vitamin B12
substitutes for
levels
calcium and
3.) patient also
vitamin B12
was
nutrients
diagnosed
3.) patient will seek
with
osteoarthritis
physical therapy
4.) patient had
to help relieve
claudication
osteoarthritis
of right
symptoms
lower leg.
4.) patient will
display no signs
of claudication of
right lower leg.
3.)
4.)
5.)
6.)
all joints as
needed
Evaluate the
need for
ambulatory aids
Provide a safe
environment:
a) Bed rails up
b) Bed in
down
position
c) Necessary
items close
by
Institute
measures to
prevent skin
breakdown
Administer
tramadol 100
mg oral q8h as
ordered by
physician.
2.) This assessment provides
data on extent of any
physical problems and
guides therapy. Testing by a
physical therapist may be
needed (Gulanick, pg. 90,
2022)
3.) Proper use of canes and
walkers and other assistance
can promote activity and
reduce dangers of falls. The
specific aid required
depends on the amount of
weight bearing that is
tolerated, and the ability of
the patient to balance safely
(Gulanick, pg. 91, 2022)
4.) These measures promote a
safe, secure environment
and may reduce risk for falls
(Gulanick, pg. 91, 2022)
5.) These measures reduce skin
breakdown, and the
compression devices
promote increased venous
return to prevent venous
stasis and possible
thrombophlebitis in the legs
(Gulanick, pg. 93, 2022)
6.) Analgesics may reduce pain
that impedes movement
(Gulanick, pg.92, 2022)
Include References:
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier.
Mayo Foundation for Medical Education and Research. (2021, January 14). Peripheral artery disease (PAD). Mayo Clinic. Retrieved
April 14, 2022, from https://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/diagnosis-treatment/drc-20350563
SKIDMORE-ROTH, L. I. N. D. A. (2022). Mosby's Drug Guide for Nursing Students. CHURCHILL LIVINGSTONE.