Care Plan

Student: Kamrie Godfrey Date: 5/18/19

Course: NSG-430CC Instructor: Kymberly Kiesling

Clincial Site: Mayo Clinic Client Identifier: EK Age: 79

Reason for Admission: Lightheadedness – presented to the E.D. on 5-18-19 at 08:05 by ambulance. She was bradycardic at 49bpm, which she
reported normal. Paramedics described positive orthostatics with heart rate jumping from 50-70bpm when changing from sitting to standing.
Blood pressure, however did not change with position (the paramedics continued to call this positive orthostatics). Upon arriving to the E.D., the
patient described very subtle right-sided chest pain rated 1/10, with no nausea or vomiting. EK describes a fall 2 days ago that she says she
doesn’t remember, but that she knows happened because she woke up with bruises and lacerations on her arms. This morning she woke up
feeling lightheaded and nervous because of her recent reported fall.

Medical Diagnoses: Idiopathic benign paroxysmal positional vertigo Clinical Manifestation(s):

Pathophysiology: Vertigo occurs due to the organs and crystals in Presented: Lightheadedness, loss of balance.
your ear not remaining balanced. The otolith organs in your ear Expected: Dizziness, spinning sensation, loss of balance,
monitor head movements. The crystals inside the organs make you
nausea, vomiting (Mayo Clinic, 2019).
sensitive to gravity and when they become dislodged, the can
move into the semiciruclar canals. This event causes dizziness and
sensitivity to head position changes (Mayo Clinic, 2019).
Risk factors: Age, recent fall, a past episode of dizziness, head
injury (Mayo Clinic, 2019).

Assessment Data
Subjective Data: Patient reports falling out of bed and getting back into bed without remembering it. “I have bruises all over me, so I know I
fell.” “I don’t remember falling, but I woke up super dizzy and weak this morning.” R-sided chest pain rated 1/10.

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

VS: 08:15 Labs: Diagnostics:
T : 36.0 C No abnormal labs CT head 05/18 at 09:10
BP: 161/78 Reason: lightheadedness, suspected unknown
epilepsy/tumor
HR: 56 –sinus bradycardia
Showed: no abnormalities or bleeding
RR: 14
O2 Sat: 96% RA
VS: 09:05
T: 36.1 C
BP: 160/80
HR: 49 – sinus bradycardia
RR: 16
O2 Sat: 97% RA

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Assessment: Orders:
PMH: Hyperlipidemia, hypertension, bilateral mastectomy, bilateral CT head w/o contrast – rule out tumor, epilepsy, bleeding.
hearing loss, syncope vasovagal, GERD.
PT consult and treatment– assess for possible vertigo, perform Epley
Neuro: The patient is alert and oriented x3. Pupil size is 3 mm maneuver.
bilaterally. The pupil reactions are brisk bilaterally and the pupils are
ECG 12 lead – showed sinus bradycardia.
regular bilaterally. Her glasgow coma score is 15.
CBC w/ differential – check troponin T 5th generation STAT
Respiratory: The patient’s respirations are regular with symmetrical
chest expansion. There is no cough and no sputum. Lung sounds are Full code
clear throughout and equal bilaterally. The head of bed is at 45 degrees.
Patient is breathing at 14 respirations/min with a O2 saturation of 96%
on room air.
Cardiac: An EKG 12 lead showed sinus bradycardia at 56 bpm. The
nail beds are pink and capillary refill is <3 seconds bilaterally. Blood
pressure is 160/80.
GI: Last bowel movement was 5-17-19. The abdomen is soft and
rounded. She has normal bowel sounds x4.
GU: Patient is continent. Her urine is yellow, clear, and odorless
(assessed before taken to lab). Intake and output were not recorded as
the patient was in the E.D. for less than 4 hours.
Muscoloskeletal: No compression devices or antiembolism stockings
are on. Patient ambulates independently and has good ROM. Strength is
equal on upper and lower body extremities with and without resistance.
Integumentary: Skin color is appropriate for ethnicity and skin
temperature is warm and dry. The patient has normal skin turgor. The
mucuous membranes are pink and moist. The patient has a laceration
measuring 2 inches on her right elbow as well as a round hematoma 3
inches in diameter around the lac. She also has a 1 inch laceration on
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her left lower forearm and another hematoma measuring ½ inch in
diameter on her right patella. The hematomas are purple in color and
hard in the center.
Lines: She has a right saline locked peripheral IV 22-gauge in the
antecubital region. It is patent and gets blood return. Saline locked?
Infusing?

Medications
ALLERGIES: NKDA

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 Name Dose Route Frequency Indication/Therapeutic Adverse Effects Nursing
Effect Considerations
Atorvastatin 10 mg PO QD Lipid-lowering agent; CNS: amnesia, confusion, dizziness, headache, Assessment
(Lipitor) 1 tab patient has a history of insomnia, memory loss, weakness • If patient develops
hyperlipidemia EENT: rhinitis muscle tenderness
Resp: bronchitis during therapy, CPK
CV: chest pain, peripheral edema levels should be
GI: abdominal monitored. If CPK
cramps, constipation, diarrhea, flatus, heartburn, levels are >10 times
altered taste, drug-induced hepatitis, dyspepsia, the upper limit of
↑ liver enzymes, nausea, pancreatitis normal or myopathy
Endo: hyperglycemia occurs, therapy should
GU: erectile dysfunction be discontinued.
Derm: rashes, pruritus • Monitor liver function
MS: RHABDOMYOLYSIS, arthralgia, tests prior to initiation
arthritis, immune-mediated necrotizing of therapy and as
myopathy, myalgia, myositis clinically indicated.
Misc: HYPERSENSITIVITY REACTIONS • Perform muscle biopsy
INCLUDING ANGIONEUROTIC EDEMA to diagnose; shows
necrotizing myopathy
(Vallerand et al., 2017). without significant
inflammation.
Teaching
• Instruct patient to
notify health care
professional if
unexplained muscle
pain, tenderness, or
weakness occurs,
especially if
accompanied by fever
or malaise.
• Advise patient that this
medication should be
used in conjunction
with diet restrictions
(fat, cholesterol,
carbohydrates,
alcohol), exercise, and
cessation of smoking.
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 • Emphasize the
importance of follow-
up exams to determine
effectiveness and to
monitor for side
effects.
(Vallerand et al., 2017).

Amlodipine 5 mg PO BID Antihypertensive; patient CNS: dizziness, fatigue Assessment

(Norvasc) 1 tab has hypertension CV: peripheral edema, angina, bradycardia, • Assess location,
hypotension, palpitations duration, intensity, and
GI: gingival hyperplasia, nausea precipitating factors of
Derm: flushing patient's anginal pain
• Monitor intake and
(Vallerand et al., 2017). output ratios and daily
weight.
• Assess for signs of HF
(peripheral edema,
rales/crackles,
dyspnea, weight gain,
jugular venous
distention)
Teaching
• May cause drowsiness
or dizziness. Advise
patient to avoid
driving or other
activities requiring
alertness.
• Caution patient to
change positions
slowly to minimize
orthostatic
hypotension
• Advise patient to
notify health care
professional if
irregular heartbeats,
dyspnea, swelling of
hands and feet,
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 pronounced dizziness,
nausea, constipation,
or hypotension occurs.
(Vallerand et al., 2017).

Aspirin 81 mg PO QD Nonopiod analgesic/blood EENT: tinnitus Assessment

DR tab thinner; patient rated chest GI: GI bleeding, dyspepsia, epigastric • Assess pain type,
pain 1/0. distress, nausea, abdominal pain, anorexia, location, and intensity
hepatotoxicity, vomiting before and after
Hemat: anemia, hemolysis administration.
Derm: rash, urticaria • Monitor for fever,
Misc: Anaphylaxis, laryngeal edema diaphoresis and
tachycardia.
• Monitor for toxicity.
(Vallerand et al., 2017).
• Monitor liver enzymes
before and after, as
well as bleeding time.
Teaching
• Instruct patient to take
with a full glass of
water.
• Avoid alcohol for risk
of GI bleeding or
irritation.
• Report ringing of the
ears, bleeding of the
gums, fever, and easy
bruising.
(Vallerand et al., 2017).

Losartan 50 mg PO QD Antihypertensive; patient CNS: dizziness, fatigue, headache, insomnia, Assessment

(Cozaar) 1 tab has hypertension. weakness • Assess BP lying,
CV: chest pain, edema, hypotension sitting, and standing,
EENT: nasal congestion as well as pulse during
Endo: hypoglycemia, weight gain initial dose.
GI: diarrhea, abdominal pain, dyspepsia, • Assess patient for
nausea signs of angioedema
GU: impaired renal function (dyspnea, facial
F and E: hyperkalemia swelling).
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 MS: back pain, myalgia • Monitor potassium,
Misc: ANGIOEDEMA, fever hemoglobin and
hematocrit.
(Vallerand et al., 2017). Teaching
• Teach patient to avoid
foods high in
potassium and sodium.
• Avoid sudden changes
in position to decrease
orthostatic
hypotension.
• Notify health care
provider if swelling of
the face, eyes, lips or
tongue occurs.
(Vallerand et al., 2017).

Mupirocin 2% Topical TID Antiinfective; patient reports Derm: topical only: burning, itching, pain, Assessment
(Bactroban) ointment having had a vaginal rash. stinging • Assess wound before
and during therapy
(Vallerand et al., 2017). • Assess for rash,
swelling, or other
hypersensitivity
reactions.
Teaching
• Instruct patient on the
correct way to apply
the medication.
• Teach about usin the
full dose of
medication.
• Avoid contact with the
eyes.
• Notify the physician if
the wound does not
heal.
(Vallerand et al., 2017).

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Pantoprazole 40 mg PO Qmorning Proton-pump inhibitor; CNS: headache Assessment
(Protonix) 1 EC patient has a history of GI: Clostridium difficile-associated diarrhea, • May cause
tab GERD. abdominal pain, diarrhea, eructation, flatulence hypomagnesemia.
Derm: cutaneous lupus erythematosus Monitor serum
Endo: hyperglycemia magnesium prior to
F and E: hypomagnesemia (especially if and periodically during
treatment duration ≥3 mo) therapy.
GU: acute interstitial nephritis • Assess patient
Hemat: vitamin B12 deficiency routinely for epigastric
MS: bone fracture or abdominal pain and
Misc: systemic lupus erythematosis for frank or occult
(Vallerand et al., 2017). blood in stool, emesis,
or gastric aspirate.
• Monitor I&O, and
encourage fluid intake
Teaching
• Advise patient to avoid
alcohol, products
containing aspirin or
NSAIDs, and foods
that may cause an
increase in GI
irritation.
• Advise patient to
report onset of black,
tarry stools; diarrhea;
or abdominal pain to
health care
professional promptly
• Instruct patient to
notify health care
professional of all Rx
or OTC medications,
vitamins, or herbal
products being taken
(Vallerand et al., 2017).

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 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 skin integrity related to vertigo as evidenced by 2 lacerations and 2 hematomas. (Phelps, et al. 2017).
This is the primary diagnosis because lacerations put the patient at risk for infection.
Patient will remain free of Patient will continue to 1. Inspect lacerations and 1. Changes in condition 1. Goal met.
signs of infection or have a normal WBC count skin every 2 hours and should be noted and Lacerations were
complications. by discharge. document. reported to the HCP. monitored and did
2. Take a CBC to monitor 2. An increased WBC not show signs of
WBC. count could mean a infection.
3. Position patient for possible infection. 2. Goal met. WBC’s
comfort. 3. Changes positions will remained within the
promote relaxation, normal range.
circulation, and 3. Goal met. Patient
(Phelps, et al. 2017). reduced pressure on reported being in a
tender areas. comfortable position
(Phelps, et al. 2017). without pressure on
her wounds.
Secondary Nursing Diagnosis: Risk for falls related to vertigo.
(Phelps, et al. 2017).
Patient will remain free Patient will rate her 1. Consult PT to perform 1. Physical therapy will 1. Goal met. PT was
from falls. lightheadedness and the Epley maneuver. be able to perform the consulted and the
dizzines a 1/10 by the time 2. Teach patient how to Epley maneuver for Epley maneuver was
of discharge. take her own blood vertigo treatment. performed.
pressure at home.
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 3. Assess the patient’s 2. This will help the 2. Goal met. Patient
dizziness after PT. patient to know performed teach-back
4. Review medications whether or not she is on how to take BP at
with the patient. experiencing home.
orthostatic 3. Goal met. Dizziness
(Phelps, et al. 2017). hypotension. resolved, vertigo was
3. If the dizziness confirmed.
resolves, vertigo can 4. Goal met. Medications
be confirmed. were reviewed.
4. If the patient is on
antihypertensives, this
could cause
lightheadedness.
(Phelps, et al. 2017).

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

Mayo Clinic (2019). Benign Paroxysmal Positional Vertigo (BPPV). Retrieved May 19, 2019, from

https://www.mayoclinic.org/diseases-conditions/vertigo/symptoms-causes/syc-20370055

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Ralph, S. S., Taylor, C. M., & Phelps, L. L. (2017). Nursing diagnosis reference manual. (10th ed.). Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkins.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's Drug Guide for Nurses (15th ed.)

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