NURSING 404
MEDICAL-SURGICAL NURSING
Guide for Weekly Clinical Prep/Care plan (clinical paper)
Due one week after caring for the patient
Information in blue must be completed before caring for patient
Student goals for the day:
 Getting to see the use of a ventilator
 Administering meds to patients on ICU floor
 Getting to see hemodynamic monitoring if possible.
List the interventions that you would like to accomplish with your patient that you
will require assistance with performing:
 Administering medications to pt. through a PEG tube.
I. General patient information
Age x Sex x Week of clinical x
Admitting diagnosis Pre-op Aortic Valve replacement
Surgery (if applicable) Aortic Valve Replacement on 3-10-15
Height: x
Weight: x
Allergies: Lortab
Code status: Full Code
1. Chief complaint (Why did the patient come to the hospital?)
Patient came in pre-op because he was having an aortic valve replacement
due to aortic stenosis, after operation patient suffered a stroke while in recovery and
was admitted into the ICU.
2. Review general health (past medical history; other health problems)
Health problems- Aortic Stenosis, hypertension
Allergies- Lortab
3. Potential medical/psycho/social/cultural barriers to care:
Patient has Dysphagia due to stroke so it is difficult for him to communicate,
also patient is very fatigued.
4. Brief pathophysiology
Aortic Stenosis- Narrowing of the valve opening that has increased resistance to the
blood flow being ejected from the left ventricle into the Aorta (Porth,2011).
Stoke- Results from injuries to the tissues of the brain due to vascular disorder, it is the
disruption of blood flow in a vessel of the brain (Poth, 2011).
Dysphagia- Results from diseases/illness causing narrowing of the esophagus, decreased
salivary secretions, and weakness of the muscular structures of the oral mucosa (Porth,
2011).
Hypertension- Can result from an underlying cause/illness. Occurs when systolic pressure
is <140 mm Hg or diastolic pressure is <90 mm Hg. When narrowing of the blood vessels
occurs and blood volume ejected results in increased (Porth, 2011).
5. Medications (dose, route, frequency, reason for getting, know nursing implications)












Amiodarone- dose-200mg , route-PO/NG-oral susp., frequency- BID, reason for getting-antiarrythmic, know nursing implications- Monitor ECG closely, Monitor/Assess for signs of
pulmonary toxicity, monitor BP frequently (Davis’s drug guide).
Aspirin chewable-dose- 81mg, route- PO/NG, frequency-1x daily, reason for gettinganticoagulant, know nursing implications- Monitor/Assess for signs of hypersensitivity,
Monitor aspirin levels periodically, Assess for rash(Steven-john’s syndrome) (Davis’s Drug
Guide).
Carvedilol-dose- 6.179 mg, route-NG, frequency- BID, reason for getting-hypertension,
know nursing implications-monitor BP and pulse closely, monitor for orthostatic
hypotension, Monitor I & O’s (Davis’s Drug Guide).
Furosemide-dose-40 mg, route-IV, frequency- BID, reason for getting-edema, know nursing
implications-Assess fluid status, monitor weight status, monitor I & O’s ( Davis’ s Drug
Guide).
Insulin Lispro-dose- 1-7 units on sliding scale, route- Sub Q, frequency- w/ meals HS, reason
for getting- Blood sugar control, know nursing implications-Monitor for signs/symptoms of
hypoglycemia, monitor daily weights.
Silvadene-dose- 1% cream, route-topical, frequency-BID/PRN, reason for getting- wound on
L side of penis, know nursing implications- Monitor for rash (Rxlist.com)
Elta trivase-dose-2% cream, route-topical, frequency-BID, reason for getting- wound care,
know nursing implications- N/A
Lisinopril-dose- 2.5 mg, route- PO/NG-oral susp., frequency-BID, reason for gettingHypertension(Rxlist.com), know nursing implications-Monitor for orthostatic hypotension
K+/Cl- (Kayceil)-dose- 40 mEq, route-PO/NG, frequency- BID, reason for getting- mineral
supplement, know nursing implications- Monitor for signs/symptoms of hypo/hyperkalemia,
Monitor ECG tracings (Rxlist.com)
Ranitidine- dose- 150 mg, route- enteral, frequency- daily, reason for getting-prevention of
stress related peptic ulcers (Rxlist.com), know nursing implications- Assess for
epigastric/abdominal pain, monitor for occult/frank blood in the stool (Davis’s drug guide)
Vancomycin- dose- 1,000mg , route-IVBP, frequency- Q 18 hrs., reason for getting-MRSA in
the sputum, know nursing implications- Assess/monitor for signs of infection, check IV site
periodically, Assess for anaphylaxis (Davis’s drug guide).
Warfarin- dose-2.5 mg , route-PO, frequency-daily, reason for getting- anticoagulant, know
nursing implications- Assess for signs and symptoms of hemorrhage/bleeding, Assess for
signs of thrombosis (Davis’s drug guide).
6. Labs: give patient result and normal range; for abnormal results give possible
reasons for the abnormal results and how the abnormality might affect the patient.
Lab
HCT
Pt
result
27.2
Normal
range
34-46.8
Hgb
9.0
11.6-16
Na
K
142
4.1
136-145
3.5-5.1
If abnormal: why
Affect on patient
Pt had surgery for
valve replacement,
blood loss occurred,
Pt also on tube
feedings not getting
enough iron perhaps?
Patient had a stroke,
less oxygenated blood
circulating
Pt. is fatigued and can
affect organ function and
healing.
Pt. is fatigued with little
energy
Glucose
144
70-110
BUN
28
7-18
creatinine
1.4
0.6-1.3
WBC
ABG
pH
CO2
HCO3
Others-
7.2
3.2-10.6
n/a
26
n/a
N/A
7.42
Pt is on hypertensive
meds that cause rise
in BS (Davis’s drug
guide).
Pt is on hypertensive
meds that can cause
rise in BUN as a result
of consumption
(Davis’s drug guide).
Pt. on Zantac for
prevention of ulcers,
med. Has side effects
of causing serum
creatinine to become
elevated (Davis’s drug
guide).
Has to get BS sugar checks
before meals, disrupts rest.
Pt. has increased thirst,
BUN elevations can cause
dehydration (Porth,2011).
Some type of kidney
impairment is starting to
manifest, kidneys not
getting rid of waste
products properly
(Porth,2011).
23.0-32.0
22-28
N/A
II. Assessment: Complete as much as possible of this section before caring for the patient
Health Perception – Health Management
Pt has a hx of hypertension, this hypertension led to the pt. having aortic valve stenosis,
came in on 3-10-15 to do pre-op admission and surgery, while recovering from surgery
the pt. suffered a stroke. After patient was stabilized pt. was admitted to the ICU and was
placed on anti-coagulants. Pt. also has dysphagia due to stroke and upper and lower
extremity weakness.
Nursing Dx.

Risk for infection r/t surgical wound on chest

Risk for bleeding r/t anti-coagulant therapy

Risk for falls r/t upper/lower extremity weakness secondary to Stoke.
**After caring for the patient list nursing diagnoses related to health perception/health
management:
Nutritional/Metabolic
1. Diet which has been ordered for the patient: thick solids as tolerated with chin
tucking when swallowing.
Is the patient getting tube feedings? Yes
If so, what and how often: Promote, 30 ml/hr q 6 hrs.
2. IV fluids and rates: NS with Antibiotic PB
3. Finger stick blood sugar testing? Yes
If so, how often: Before q meal & HS.
**After caring for the patient list nursing diagnoses related to nutrition/metabolism:
Nursing Dx.

Impaired Swallowing r/t Stroke AEB chin to chest tuck, delayed swallows,
clearing of throat.

Impaired skin integrity r/t catheter pressure sore AEB Pain 6/10 pain scale,
redness, discharge from L side of penial head.

Impaired tissue integrity r/t Altered circulation AEB bilateral complete
meta-tarsal necrosis, decreased sensation on feet, delayed cap-refill >3.

Risk for aspiration r/t dysphagia
Elimination
1. Does the patient need to have I & O documented? No
a. What intake will you need to document
2. Bedpan or bedside commode? Bed pan available upon request or need of patient
Assistance to bathroom? Assistance with bedpan
3. Last BM 3-31-15.
4. Drains/tubes/ostomy: R Double Lumen PICC line, LLQ PEG tube.
**After caring for the patient list nursing diagnoses related to elimination:
Nursing Dx.
 Constipation r/t immobility AEB pt statements of “I have to really push”,
decreased volume of stool, hypoactive bowel sounds.
 Impaired Urinary elimination r/t decreased sensory/motor sensations AEB
episodes of urinary incontinence, urgency, and frequency.
Activity/Exercise
1. Activity order for this patient: As tolerated
2. How many times will you plan to get this patient out of bed while you are
caring for him/her? At least a few times and while PT works with him.
3. What will be the best time to get the patient up? In the early/mid afternoon
4. Type of bath you plan for this patient: Pt. is getting sponge/ at the bedside baths.
5. How often/when do you plan to do mouth care? Q 2 hrs, and before q meal
6. Is the patient receiving supplemental oxygen? How much? No By what method?
N/A
7. Is the patient on a ventilator? No If so, what are the settings? N/A
Mode_______Rate____TV or PIP______FiO2_____Peep____Pressure Support____
Last ABG: pH- N/A CO2- 26 HCO3-_N/A
8. What is the plan for checking vital signs? Q3
9. Other hemodynamic monitoring (CVP, CO, PAWP, SVO2, etc)? N/A
10. Heart rhythm monitoring? Telemetry Rhythm: Normal Sinus w/some episodes
of A-fib
11. Other monitoring? Continuous BP
**After caring for the patient list nursing diagnoses related to activity/exercise:
Nursing Dx.
 Activity Intolerance r/t weakness AEB patient statements of “I’m tired/sleepy”,
pallor bilaterally in upper extremities, and increased exertion with activities.
 Decreased Cardiac Output r/t structural changes in the heart anatomy(aortic
stenosis) AEB edema, fatigue, pallor of the extremities.
Sleep/Rest
Which planned interventions may interfere with this patient’s sleep/rest?
Morning med. Administration, planned BS checks, speech therapy, PT/OT.
What will you do to promote sleep/rest?
Cluster care for patient with periods of rest as needed by patient and have therapies
come in the early/mid-afternoon when pt. is more awake and alert and space them
out so pt is not getting overwhelmed and can energy to do the work needed for the
therapy staff.
**After caring for list nursing diagnoses related to sleep/rest:
Nursing Dx.
 Insomnia r/t sleep pattern impairment secondary to nursing interventions AEB
fatigue, lack of energy, sleepiness throughout the day.
Cognitive/Perceptual
**After caring for the patient, list nursing diagnoses related to cognition/perception:
Nursing Dx.

Disturbed sensory perception: visual, kinesthetic r/t ICU admission AEB
lack of family interactions, altered balance.
Self-perception/Role Relationships
**After caring for the patient, list nursing diagnoses related to self-perception/role
relationships:
Nursing Dx.

Risk for loneliness r/t prolonged ICU/hospital admission

Anxiety: Moderate r/t change in health status AEB sleep disturbances,
insomnia, worry over changing health status.

Interrupted family process r/t illness/hospitalization AEB changes in
family structure role, isolation from community, family practices.
Sexuality/Reproduction (5%)
**After caring for the patient, list nursing diagnoses related to sexuality/reproduction:
Nursing Dx.
 N/A
Coping/Stress Management/Values/Belief Patterns (5%)
**After caring for the patient, list nursing diagnoses related to this functional health
pattern:
Nursing Dx.

Risk for Impaired religiosity r/t hospitalization
Complete sections III, IV, and V after caring for patient
III. General head to toe assessment (should usually be done by 0800 on date of care)
Vital signs: Temp- 36.4 C, HR- 73, RR-24, O2- 97 RA, BP- 89/46
LOC: Patient oriented x4
Breath sounds: Clear bilateral breath sounds upon auscultation, to dyspnea, O297% on RA
Heart sounds: No adventitious heart sounds heard upon auscultation, HR-73, S1,
S2 noted, no murmurs.
Bowel sounds: Hypoactive bowel sounds, constipation, strains to have bowel
movement, decreased amount of stool, no pain upon light palpation
Moving all extremities? Yes Strength: Bilateral weakness noted on upper and
lower extremities requires assistance when repositioning and getting up due to
weakness.
Peripheral pulses: +2 pulses bilaterally, bounding and located on pedal area.
Radial pulses were also located but later on diminished and could only be located
via Doppler.
Skin integrity: Mid thoracic vertical incision were valve replacement took place,
incision is dry, intact, no redness/drainage noted, open to air only starry strips
applied. L penial head pressure wound from catheter , sensitive to touch, redness
noted, yellow discharge noted being treated with antibiotics, silvadene, elta vase,
open to air wound dressing keep falling off when patient urinates, penis and
scrotum were placed in a sling made from a pillow case to prevent further
pressure to the area. Patient has a LLQ incision/surgical site where PEG tube was
placed for feedings and med. Administration, no redness/irritation noted.
IV sites (where are they and how do they look/function): R Double Lumen PICC
line, lines flush freely, no redness noted around site, no warmness noted, dressing
is dry and intact.
Monitoring lines (where are they and how do they look/function): Telemetry
only, pt on cardiac monitor which nurse can look at and assess from the front desk
while away from patient.
Drains (Foley, surgical drains, etc.): N/A
Dressings (where, type, drainage, etc): Dressing over PICC line insertion site,
gauze pad sealed/secured with tegaderm.
Braden Score: did not obtain
Other focused assessment: PEERLA, sclera clear, patent nares, oral mucosa
moist, getting oral care, head round evenly distribution, facial symmetry,
decreased sensation on buccal bilaterally, intact dentin, pallor of the upper and
lower extremities, cool to the touch, cap refill > 3, no tenting, delayed
swallowing. Necrosis of the metatarsals noted bilaterally with some sensation still
intact.
IV. Look at all of the nursing diagnoses from the above assessment. Prioritize the first 5
nursing diagnoses according to which are most threatening to the life and integrity of the
patient and/or family. Include at least one psychosocial nursing diagnosis.
1.
2.
3.
4.
5.
Top 5
Impaired Swallowing r/t Stroke AEB chin to chest tuck, delayed swallows,
clearing of throat (Doenges,2010).
Decreased Cardiac Output r/t structural changes in the heart anatomy
(aortic stenosis) AEB edema, fatigue, pallor of the extremities (Doenges,2010).
Impaired skin integrity r/t catheter pressure sore AEB Pain 6/10 pain scale,
redness, discharge from L side of penial head (Doenges, 2010).
Impaired tissue integrity r/t Altered circulation AEB bilateral complete
meta-tarsal necrosis, decreased sensation on feet, delayed cap-refill >3 (Doenges,
2010).
Interrupted family process r/t illness/hospitalization AEB changes in
family structure role, isolation from community, family practices (Doenges,2010).
V. Care Plan: make a plan of care for one of the priority nursing diagnoses. Each clinical
paper must have a care plan for a nursing diagnosis which is different from previous
papers.
A. Assessment- Listed above on General Assessment
B. Nursing diagnosis-Impaired Swallowing r/t Stroke AEB chin to chest tuck,
delayed swallows, clearing of throat (Doenges,2010).
C. Expected Outcome
:
 Patient will be able to take food (Thicken solids) PO by the end of the nursing
clinical shift on 3-31-15 without aspirating (Doenges, 2010).
 Patient will maintain hydration status throughout hospitalization stay (Doenges,
2010).
 Patient will advance to a regular diet as tolerated by the time of discharge from
hospital facility.
D. Interventions
 #1-The nurse will assess and note any hyperextension of head during
consumption of meals (Doenges, 2010).
 #2-The nurse will raise the head of the bed when the client is consuming food and
instruct patient to put chin to chest when swallowing (Doenges, 2010).
 #3- The nurse will provide suction or instruct client on how to suction if possible
(Doenges, 2010).
E. Rationales
 #1- Will help the nurse determine the inability of patient to complete the
swallowing process (Doenges, 2010).
 #2- This will help the client in reducing the risk of aspiration (Doenges, 2010).
 #3- This will help the patient in reducing risk of aspiration while promoting
airway patency/safety (Doenges,2010).
F. Evaluation
 Outcome #1- Outcome was successful, patient began to have ice chips, and started
consuming yogurts to build up to reg. diet and work esophageal muscles no signs.
 Outcome #2- During clinical shift on 3-31-15 patient did maintain hydration
status which was assessed by skin turgor, could not assess if it maintained through
hospital stay.

Outcome #3- Could not assess or measure if this outcome was reached because I
did not remain with patient throughout hospital stay.
Works Cited
1. Vallerand, A. H., Deglin, J. H., & Sanoski, C. A. (2012). Davis's Drug Guide for
Nurses. Philadelphia: F. A. Davis Company.
2. Online resource- Rxlist.com
3. Porth, C., & Porth, C. (2011). Essentials of pathophysiology : concepts of altered
health states. Philadelphia : Wolters Kluwer/Lippincott Williams & Wilkins.
4. Doenges,M, Moorhouse, M.F, Murr, A. (2010). Nurse’s Pocket Guide:
Diagnoses, Prioritized Interventions, and Rationales. Philadelphia: F.A Davis
Company.