Running head: MED-SURG PATIENT CARE PLAN
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Med-Surg Patient Care Plan
Dayle Lauren
Stenberg College
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MED-SURG PATIENT CARE PLAN
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Med-Surg Patient Care Plan
Identifying Data and General Description- The patient, D.C. is a 65 year old married
Caucasian female, abdominally obese, suffering from overall poor health and in great
discomfort.
Chief Complaint/History of Present Illness- D.C. presented to the emergency room
complaining of shortness of breath (dyspnea) and overall malaise. D.C. was flagged for CHF at
emergency as well due to her cardiac history and her presentation of exacerbated anaemic
symptoms and advanced COPD symptoms. *
Past Medical History- D.C. has a history of advanced COPD, pneumonia, DM2 with insulin,
microcytic anaemia, HTN, high lipids, decreased T4, obesity, GERD, OA, AKI, CVA, and an
ex-smoker
Surgical History- There are no known surgical histories for this patient
Allergies- penicillin
Disease ProcessDiagnosis: COPD
Etiology: Largely caused by smoking (80-90% of cases), occupational chemicals and
dusts, infection (recurring respiratory tract infections), heredity (AAT deficiency, the only
known genetic abnormality that leads to COPD), and aging, COPD is a progressive respiratory
disorder with partially reversible airflow obstruction, usually confined to the lungs although with
progression of the disease, can advance to include skeletal muscle dysfunction, right heart
failure, depression and altered nutrition (Lewis, McLean Heitkemper, Ruff Dirksen, Graber
O’Brien, & Bucher, 2010). According to Lewis et al., (2010), it is commonly associated with
emphysema and chronic bronchitis, and as well, some patients can have asthma concurrently.
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Clinical Signs and Symptoms: If a patient is complaining of symptoms of cough,
production of sputum, dyspnea and a history of smoking or exposure to any of the risk factors for
the disease listed above, a diagnosis of COPD should be considered (Lewis et al., 2010). An
intermittent cough is one of the earliest signs of COPD, and is accompanied by small amounts of
sputum being produced and during the winter months further exacerbation may be experienced
(Lewis et al., 2010). Dyspnea, according to Lewis et al., is one of the symptoms that is typically
disregarded until it progresses to the point of interfering with daily activities such as bathing,
carrying groceries or cooking (2010). As progression of dyspnea continues, the patient develops
a barrel-chest appearance as greater quantities of alveoli over-distend and trap increased amounts
of air; accessory respiratory muscles are used instead of the diaphragm to assist in breathing at
this stage as well (Lewis et al., 2010). Lewis et al explain that the advanced COPD client also
exhibits signs of weight loss, although the exact reason for this is not fully understood (2010). A
physical examination will usually result in the discovery of an extended expiratory phase of
respiration, along with adventitious lung sounds such as wheezes and decreased breath sounds in
some or all lung lobes (Lewis et al., 2010).
This particular patient’s COPD was advanced to the point where it lead to the
development of other conditions such as HTN, pneumonia, and depression (Lewis et al., 2010).
Lab Results- Diagnostics done for this particular patient included Hematology profile (CX3,
CBC, Glucose, Creatinine, Electrolytes, Urea, Calcium, Troponin, INR, PT, anaemia tests,
Thyroid tests (TSH and Thyroxine), and occult blood (stool). Other diagnostics and tests include
ECG, Old ECG, X-ray and CXR, LFTs and Lipase.
This patient had regular hematology profiles done which indicated high WBC levels of
11.5, low hemoglobin at 109, a mean cellular volume of 80 (low), a high red cell distribution of
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19.2, high neutrophil counts at 9.58 and high monocyte counts of 1.15. Her troponin levels were
also elevated somewhat at 0.49. These levels were indicative of exacerbation of the patient’s
microcytic anaemia, pneumonia infection and suspected CVA/Congestive heart failure. This
patient was suffering from multiple concurrent system failures. 
An echocardiogram indicated that this patient had an ejection fraction of only 35% (the
amount of blood being ejected out to the body from the ventricles) with a subsequent pan
chamber enlargement (indicative of congestive heart failure), cardiomegaly (enlargement of the
heart), and some sclerosis of the aortic valve and extensive calcification of the coronary arteries.
All of these presentations result in varying degrees of heart failure, and in conjunction with the
deficit lung function due to the COPD, this patient has overall poor tissue perfusion and resultant
system failures.*
Blood pressure readings taken both supine and standing were indicative of postural
hypertension, with BP readings ranging from 114/69 supine and 113/63 standing. Potassium
levels were still elevated, being extremely high upon admission, but slowly dropping. This is
indicative of HTN and CHF.
Blood glucose levels were monitored QID and ranged between 16 upon admission to 9.5
on the days I had this patient. The patient was on both lispro and isophane NPH insulin with
supplemental insulin sub-Q QID. On both days that I had this patient she required supplemental
insulin due to the high blood glucose values. Her insulin orders at one point changed twice in
one 8 hour shift.
The patient was also monitored for liver function during her stay, and with the liver panel
hematology profile, her results showed high AST levels (1668), high ALT levels (934) and high
MED-SURG PATIENT CARE PLAN
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GGTP levels (198). These results indicate hepatocyte damage and bile duct damage, and also
are indicative of hepatitis or cholestatic disease (Brown & Shah, 2012). 
Nursing Physical Assessment- A thorough head to toe assessment of D.C. showed marked
changes throughout the two days that this patient was under my care. Assessments were
performed in an ongoing and consistent manner due to her dynamic health issues and precarious
levels of health. Throughout both days, D.C. was alert and oriented X 3. It was noted, however,
that her level of cognition was impaired with some hallucinations and delusions following
administration of pain medications. Pain was rated as 8 out of 10 on the left side of her abdomen,
where ascites was present. Apical pulse was regular and pedal pulses were not palpable. Edema
was absent from all peripheral limbs. Her skin was warm and dry and color was pale and sallow.
Respirations were easy with crackles heard in mid-lobe of L lung. Patient presented with a dry
barking cough at times, with no presentation of sputum. Patient’s intake was low of fluids and
consumption of meals was very small. Abdomen was soft upon palpation and bowel sounds
were present X4. Patient complained of pain in upper R quadrant. Abdominal CT scan
requisitioned. Patient did not have a bowel movement during my time with her, and had been
without one for 4 days. Bowel protocol was initiated. Patient was also not voiding regularly due
to low fluid intake. Bladder scans performed and Foley catheter was introduced. Patient was
assisted to walker for transfers and encouraged to mobilize daily. Pedal pulse not palpable on
either foot; edema began to display along with poor tissue perfusion evidenced by cold skin and
discoloration, as well as accumulation of edema.
Treatment Plan- Treatment plan on the unit for this patient was focused on stabilization of her
failing systems. Monitoring of her vitals was done every 3 hours depending on her status at any
given moment. Blood tests were done every 3 hours as well. This patient had a medical regimen
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that changed very frequently, sometimes a few times in a shift. Her medication included antihypertensives, corticosteroids, antibiotics, proton-pump inhibitors, bronchodilators, antihyperglycemics, insulin, anticholinergics, blood thinners, anti-clotting agents, thyroid hormones,
antacids, pain killers, antidepressants and acidophilus. Patient was not well enough to partake in
care plan as she was in acute stages of multiple co-morbid system failures.
Teaching and Discharge Plan- This patient requires education and teaching for maintenance of
diabetes, proper nutritional intake, compliance and organizational help with extensive medication
regimen, further understanding of underlying conditions such as COPD and HTN and associated
signs and symptoms of worsening or changing conditions in her health. This patient also requires
some further education on healthy lifestyle changes, and community support for her depression
and unhealthy family dynamics. 
Anticipated discharge plan: Patient will maintain a balanced diabetic diet and
successfully monitor blood glucose levels and insulin self-administration. Patient will achieve
this by partaking in diabetic teachings while on unit with Diabetic Nurse and care team. Patient
will also successfully consult with Dietician and will be able to reiterate and explain proper
diabetic diet protocol and insulin use and administration process and procedures.
Patient will also maintain healthy blood pressure rates through adherence to prescribed
medications, daily home BP monitoring and lifestyle and diet changes as discussed by doctor and
dietician. Patient will be able to tell care team what each medication is for, when it must be
taken, and proper dosages. Patient will also be knowledgeable in applicable signs and symptoms
of adverse effects of medications and possess knowledge of when the doctor must be called to
consider re-evaluation of symptoms or medication schedule. 
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Patient will have Senior’s community support in place for home monitoring of medical
regimen and support when required for ongoing depression. Patient will be assessed for ability to
maintain ADLs and supports in place for any areas of deficit if required. Support will be in place
to assist in counselling for elderly husband and education of his wife’s condition and his role as
caregiver.
Student ReflectionLikely the most impactful realization when working with this client was how
interconnected the body systems are. Through my experience in working with this complex
patient, I learned how important lab values are, as well as the proper interpretation of them in
conjunction with a full understanding of each diagnoses, and how one affects the other. This
particular patient was the most acute patient on the ward and was very unstable for a number of
days. She was on the ward for 6 weeks and was just discharged last weekend, looking like a
completely different person from when I had her for two days. I realized how fragile life really
is, and when it hangs in the precipice of going horribly wrong, how collaborative care and solid
teamwork is key to the successful recovery of the patient. I have a new found respect for health
care professionals working in acute settings, and how diligence and a thorough understanding of
underlying disease and etiology are so very important. What really became evident as I watched
the various disciplines on her care team in action was how valuable current knowledge and
medical information is to the success of patient care.  excellent reflection.
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Nursing
Diagnosis
Desired Outcomes
Impaired
Spontaneous
Ventilation
Goal: Patient will have
COPD managed with
proper medication and
will maintain proper O2
levels By When? *

Patient displays
low SpO2 levels
Patient displays
SOB at rest and
with exertion
Patient will:
 maintain an
SpO2 level of
98% or higher
 Patient will
show lowered
levels of
anaemia
Nursing Interventions
Independent (I)
Collaborative (C)
 Care team will
ensure regular
oximetry
monitoring and
O2 therapy as
required (C)
 Nurse and care
team will
cooperate with
daily assessments
and subjective
gathering of
assessment
information*
Rationale and
APA
Reference
Increased
ventilation
allows for
proper O2
delivery to
tissues and
proper tissue
perfusion to all
areas of the
body.
(Lewis et al,
2010) 
there should
be a rationale
for each
intervention.
Evaluation of
Interventions
Patient able to
maintain proper
levels of oxygen
in the blood, as
well as proper
tissue perfusion
to all organs.
Hematology
profiles show
near-normal
values in
consideration of
maintenance of
underlying
conditions
Patient unable to
manage
ventilation levels
on own
Deficient
Knowledge

Patient lacks
understanding of
underlying health
conditions
Patient unable to
explain the reason
for the acute
decline in health
Patient unable to
maintain
medication
regimen and
necessary levels
of health
Patient lacking
necessary support
and resources to
Goal: Patient will be able
to answer questions
regarding self-care of
underlying conditions,
diabetic diet, COPD
management and
necessary lifestyle
changes and medication
protocol by end of
hospital stay
Patient will:
 Partake in
educational
sessions with
care staff.
 Demonstrate
knowledge when
asked
 Understand the
etiology and
progression of
all diagnoses


Nurse and care
team will spend
time daily in
teaching patient
about proper
health
maintenance (C
)
Collaborative
team such as
diabetic nurse
will educate
patient in proper
diabetic lifestyle
maintenance
(C)
Education of
health
maintenance
results in higher
levels of
successful
recovery (Ho &
Yan, 2010)
Patient able to
answer care team
questions
surrounding
health and illness
in satisfactory
manner
Patient displays
knowledge
necessary to
maintain own
health
See
comments
above for
interventions
and rationale. Patient able to
understand
proper
medication
regimen and has
system in place
for proper
maintenance of
medication
regimen
Patient has
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maintain
optimum levels of
health
Ineffective SelfHealth
Management
Goal: Patient will be able
to identify and maintain
levels of self-health on
return home.


Patient unable to
maintain proper
insulin care
Patient unable to
maintain proper
ventilation with
COPD
Patient unable to
change lifestyle
requirements to
maintain health
Patient lacks
proper support
and resources to
assist with health
maintenance
Patient will:
 adhere to
changes in
lifestyle
 adhere to
medication
regimen to assist
with diabetes
and COPD
 organize and
maintain proper
support and
resources for
ongoing
assistance with
health issues

Nurse and
collaborative
team will provide
patient with
resources to offer
necessary support
(C )
Nurse and care
team will support
and encourage
patient through
education and
medical care in
the acute setting
Chronic disease
selfmanagement
education
assists patients
in managing
their diseases
with confidence
(Ho & Yan,
2010).
See
comments
from first
care plan.
necessary
community and
family supports
in place to help
with health
maintenance
Patient and
support team
display
motivation and
desire to maintain
optimal health
Patient
demonstrates
quality levels of
self awareness
and self care
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References
Brown, T., & Shah, S. (2012). USMLE Step 1 Secrets. Retrieved from
http://books.google.ca/books?id=uQ9BKZ1BXTYC&pg=PT478&dq=high+AST,+ALT+
and+GGTP+levels&hl=en&sa=X&ei=qh8UZ_qLsnviQLXlYEY&ved=0CFAQ6AEwBA
Ho, E. M., & Yan, C. C. (2010). Patient education in chronic disease management. Singapore
Nursing Journal. Retrieved from
http://search.ebscohost.com/login.aspx?direct=true&db=rzh&AN=2010912531&site=eho
st-live
Lewis, S. L., McLean Heitkemper, M., Ruff Dirksen, S., Graber O’Brien, P., & Bucher, L.
(2010). Nursing Management: Obstructive Pulmonary Diseases. In M. A. Barry, S.
Goldsworthy, & D. Goodridge (Eds.), Medical-Surgical Nursing in Canada: Assessment
and Management of Clinical Problems (2nd ed. (pp. 691-716). Toronto, ON: Elsevier
Canada.
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PSY 201-3 Med/Surg Theory
Case Study and Care Plan (20%)
Mark
Mark
Assigned Earned
APA Format (5%)
1
1
Well structured paper, logically &
coherently developed content
1
1
Reference list reflecting depth and
breadth of reading
1
1
Spelling, punctuation and grammar
1
1
Accuracy and depth of head to toe
assessment, treatment and teaching
plan and other pertinent information
Demonstrated critical thinking &
reflection both throughout paper and in
student reflection section
6
6
2
2
Sound rationale for ideas and
conclusions
Thoughts & opinions substantiated
with relevant & current sources
Care plans concise, patient focused
with clear diagnoses, interventions,
rationales and evaluation
2
2
1
1
5
3
See comments
Total
20
18
Well done.
Comments
Structure and Scholarly
Presentation (15%)
Content and Care Plans (80%)
Grade
18.00 / 20.00
Graded on Wednesday, 8 May 2013, 5:15 PM
Graded by
Kim Bagshaw