Natalie Williams

Nursing Intervention Synthesis/Patient Summary

Events leading to admission (ER, Direct Admit, Transfer from another facility)
Presented to the Emergency room with chest pain and SOB. The patient was put on
oxygen. The patient had an EKG which showed no ST segment elevation. Blood was drawn and
sent to lab, which showed elevated troponins. The patient was evaluated further with a cardiac
stress test, which revealed reversible ischemia in the lateral wall. Initially the patient was treated
with medical therapy, beta-blocker in the hospital, but continued to suffer from recurrent angina
symptoms. The patient was taken for a heart catheterization which showed blockage of three
coronary arteries. The patient underwent CABGx3 with grafting from the LIMA.
Presenting Symptoms/Assessment: per post-op documentation.
Post coronary artery bypass grafting times three: The patient did well after surgery and she was
able to talk and sit up on bed with assistance. Around 2:30 oclock in the morning, the patient
was still doing well when she was checked by the nurse, but at 4 oclock in the morning, she was
dysphasic. CT scan of the brain showed no acute intracranial pathology. She is not a candidate
for IV tPA due to a recent surgery and the patient was treated with intraarterial tPA by Dr.
Daghman. She is lethargic, but she opens her eyes to verbal stimulation. She did not follow
simple commands.
NIHSS: Score = 25
1. LOC 1a: = 2 1b: unable to perform = 2 1c: 0
2. Best gaze: =1 (gaze is abnormal in one eye, but forced deviation or total gaze
paresis is not present.
3. Visual: = 1 (partial hemianopia)
4. Facial palsy: = 1
5. Motor arm: a = 2 (some effort against gravity in the, but cannot maintain 45
degrees, drifts down to bed, left arm) b = 1 (Drift: limb holds 45 degrees, but drifts down
before full 10 seconds, right arm)

Natalie Williams

6. Motor leg: = 3(No effort against gravity, leg falls to bed immediately, left leg) = 2
(some effort against gravity: legs falls to bed by 5 seconds, but has some effort against
gravity, right leg)
7. Limb ataxia: = 2 (present in two limbs)
8. Sensory: = 1 (no sensory loss)
9. Best language: = 3 (mute, global aphasia: no usable speech or auditory
comprehension)
10. Dysarthria: = 2 (patient is mute)
11. Extinction and inattention: = 2
Vital Signs: Preop (day of surgery)

HR 86 bpm
Blood Pressure 168/74
RR 20
O2 sat 96% on room air
Temp 98.2 (F) oral

ECG (day of surgery)

Normal sinus rhythm P wave is present, round, and upright before every QRS
complex in a ratio of 1:1 PR Interval: .16 seconds QRS: .10 seconds
Chest X-ray: (day before surgery) Clear in all lobes, stable cardiomegaly
Lab Results

Blood glucose 142

WBC 8.6 normal
Hct 34.5% < than normal
Hgb 9.8 < than normal
Plt 324,000 normal
RBC 4.32 normal
Ctn 0.8 normal
BUN 16 normal
GFR 70mL/min/m3 < than normal
NH3+ 24mcg/dL normal
K+ 4.3 normal
Ca2+ 9.2 normal
Cl_ 102 > normal
Na+ 139 normal
Troponins > normal 0.3885
ALT 30 IU/L normal
AST 28 IU/L normal
INR 1.4 normal
PTT 29s normal

Natalie Williams

Treatment provided in ICU: Pt was intubated and on the mechanical ventilator for 6 hours and
then extubated. The patient was given propofol while on the ventilator. After extubation
morphine and norco were given for pain. The patient was able to sit on the side of the bed, cough
and deep breathe after being 12 hrs post-op. The patients CVP and PA were being monitored by
the SWAN-ganz. The patient was being given cardene for high blood pressure. Patient was
receiving fluids to maintain fluid and electrolyte balance. Patient had stroke eighteen hours postop. The patient was immediately taken for CT scan when the nurses noticed a change in mental
status. The patient was then taken for an angiogram and given intraarterial tPA. The patient was
scored on the NIH stroke scale every hour for the first 4 hours and then every 2 hours for the
next 8 hours. Patient had low bicarb levels and bicarb was given.
Patient Information:
Patient Initials: J.T.
augmentin, pine

Height: 52 Weight: 79.1kg

Allergies: adhesive bandage,

Home Meds:
Lisinopril 40mg PO BID
Metoprolol 50mg PO BID
Simvistatin 20mg PO once daily
Famotidine 40mg PO once daily
Lyrica 75mg PO BID
Lasix 40mg PO BID
Clonidine 0.2mg PO BID
Aspirin 325mg PO once daily
Lantus 70units SC once daily
Ferrous sulfate 325mg PO once daily
Past Medical History:

Hypertension
Diabetes Mellitus
Hyperlipidemia
Iron deficiency anemia
CAD, status post CABGx3 on this admission

Personal History: She smokes one pack of cigarettes a day. She drinks 2-3 times a month.

Natalie Williams

Family History: Positive for ischemic heart disease, CAD

Past Surgical History:

Back surgery
Right arm tumor removed-benign
Tubal ligation
CABGx3 on this admission

Chief Complaint: (in the ER) Chest pain and SOB

Primary Diagnosis: CVA
Pathophysiology:
A stroke is an abrupt disturbance in cerebral circulation causing neurological deficits. A stroke is
caused by cellular ischemia or intracranial hemorrhage. This patient suffered from an ischemic
cerebrovascular attack. When an ischemic stroke occurs, the blood supply to the brain is
interrupted, and brain cells are deprived of the glucose and oxygen they need to function. An
ischemic stroke can be the result of atherosclerosis, plaque build up in injured blood vessels. The
development of atherosclerosis begins with endothelial injury and inflammation, leading to
plaque formation. The plaque becomes thick and fibrous with loss of muscle cells. The sclerotic
material partially fills and/or occludes the lumen of the vessel. Platelets adhere to this, releasing
factors that initiate the coagulation-clotting cascade, forming a clot or thrombus. The clot may
either break off as an embolus traveling to a distal vessel or remain in place, occluding the
vessel. The arteriogram confirmed that the stroke was caused by the occlusion of arteries.
Neurons die when they are not perfused, which occurs with a stroke, and the neuron deaths are
manifested by sudden neurologic deficits. Stroke is a possible complication after a CABG for
patients who have CAD. Uncontrolled high blood pressure can lead to stroke by damaging and
weakening your brain's blood vessels, causing them to narrow, rupture or leak. High blood

Natalie Williams

pressure can also cause blood clots to form in the arteries leading to your brain, blocking blood
flow and potentially causing a stroke.
Diagnostic Testing and Lab Results Post Surgery:
Lab
Test/other
diagnostic
testing

Results

Normal Range

Patient Correlation

CT scan

No evidence of
hemorrhagic CVA

Negative

The patient had a CT scan to test for

a hemorrhagic stroke. The CT scan
did not show any bleeding in the
brain, therefore it was negative.

Selective
angiogram

Aortic arch is type 3.

The origin of the great
vessels is patent. Both
vertebrals are present
and the left is
dominant. Selective
injection of the left
vertebral artery
demonstrated adequate
course and diameter in
the cervical and
intracranial segment.
Some narrowing seen
at the origin of the
superior cerebellar
arteries, right more
than left. Left common
carotid artery is patent.
Mild atherosclerotic
changes seen at the
origin of the left
internal carotid artery
without significant
stenosis. Focal 60%
intracranial

Angiogram of the aortic arch, right

common carotid, left common
carotid, left vertebral artery. 2mg of
R t-pa was injected slowly into the
left internal carotid artery and
flushed with normal saline. The left
internal carotid artery enters the
skull and divide into the anterior
and middle cerebral arteries.
Injection of intra-arterial thrombin
lysis in the anterior and middle
cerebral arteries.

Natalie Williams

supraclinoid narrowing
of the left internal
carotid artery. Diffuse
atherosclerosis seen at
the anterior middle
cerebral arteries and
their main branches
with some peripheral
infarction. The
anterior and middle
cerebral arteries and
their main branches
were visualized and
demonstrated diffuse
atherosclerosis.
Ejection Fraction 45%

Outside of
normal
range
decreased
cardiac
output

The ischemic left ventricle is not

working effectively and is unable to
pump the correct amount of blood
with each beat.

Reversible ischemia in
the left lateral wall.

abnormal

Blood is not able to perfuse the

heart and the rest of the body due to
occlusion of arteries.

ECG

Sinus Tachycardia P
wave is present, round,
and upright before
every QRS complex in
a ratio of 1:1 PR
Interval: .12 seconds
QRS: .8 seconds

abnormal

Heart rate 130bpm

CBC

WBC 12.1
-neutrophils 6.5
-lymphocytes 4.8
-eosinophils 0.6
-basophils 0.1
-BANDS 0.1

> than normal

(WBC) Presence of infection and

the body is mounting an
inflammatory response.

Echocardiogram

Stress test

Natalie Williams

Hct 26%

< than normal

Hgb 8.1

< than normal

(hct) Result of blood loss in the OR,
iron deficiencies, or overhydration.

RBC 3.06
Platelets 156,000

< than normal

normal

Result of blood loss in the OR, iron

deficiencies, or overhydration.

Result of blood loss in the OR, iron

deficiencies, or overhydration.

(RBC) Result of blood loss in the

OR, iron deficiencies, or
overhydration.

Ctn 1.56

> than normal

BMP

BUN 23

> than normal

Mg+ 2.1
K+ 4.1

(Ctrn) Decreased kidney function

possible r/t medications that can
cause cause kidney damage (cipro,
acetaminophen, aspirin) or the
strain put on the kidneys as a result
of heart damage, or the result of
uncontrolled diabetes.

(BUN) Decreased kidney

function possible r/t
medications that can cause
cause kidney damage (cipro,
acetaminophen, aspirin) or
the strain put on the kidneys
as a result of heart damage,

Natalie Williams

or the result of uncontrolled

diabetes nephrotoxicity.

Ca2 7.7
Cl_ 114
Na+ 143
Glucose 209

normal

normal

> than normal

> than normal

> normal

Type II Diabetes

Iron

28.9%

> than normal

< than normal

HCO3-

19

< than normal

Possibly caused by kidneys

inability to make bicarb or loss of
bicarbonate from longstanding
diarrhea.

HbA1c

7.1%

> than normal

This level is approaching a nontherapeutic range. It is

recommended to keep the HbA1c
below 7%. The patients blood
sugar of 209 is abnormal for her,
she regularly keeps her blood sugar
between below 150.

GFR

33mL/min/1.73m2

< than normal

Decreased kidney function possible

r/t medications that can cause cause
kidney damage (cipro,
acetaminophen, aspirin) or the
strain put on the kidneys as a result

Iron deficiency anemia

Natalie Williams

of heart damage.

Liver
Enzymes

AST 38 IU/L

> than normal

ALT 46 IU/L

> than normal

Total Protein

6.2gm/dL

normal

Amount of albumin and globulins

in the blood

Albumin

3.4g/dL

normal

A protein made in the liver, this

level is almost an abnormally low
level. could be because the patient
is not receiving adequate nutrtition

Chest X-ray

Lungs clear, no
infiltration, stable
cardiomegaly

normal

no abnormalities

Urinalysis

Increase WBCs,
nitrites,

abnormal

Urinary tract infection (I was

unable to find the specific gravity)

Coagulation
Profile

PTT

65 seconds

Therapeutic range for patient on

heparin

CVP

3mm Hg

normal

Pressure of the right atrium

15mm Hg

normal

Pressure of the right atrium,

pulmonary artery, and left ventricle

PAWP

Could be increased from

medications that are toxic to the
liver ( precedex and propofol)

Assessment: ICU post CVA

BP: 101/64

HR: 130

Rhythm: Sinus Tachycardia

Temp: 99.8

FSBS: 209

Neuro Assessment: The patient opens her eyes spontaneously, but she does not talk. She tried to
say her name, but did not answer any of my other questions. She did wiggle her toes to
command.
Pupils are asymmetric, and slightly reactive to light, left more dilated than the right. She blinks
to threat. Extraocular movements are present. Face is symmetric. Hearing is intact. Shoulder
shrug is normal. Tongue protrudes in midline position

Natalie Williams

10

MOTOR: The patient was able to raise both arms equally. She did move her toes, but no other
spontaneous movements of the legs. Tone and bulk are normal in all four extremities
SENSORY: Grimaces to pinch stimulation
REFLEXES: Decreased in all extremities.
INTEGUMENTARY: Skin-warm and dry. The coccyx is non-blanching, stage I pressure ulcer,
applied tegaderm Ag mesh dressing, and covered with a padded bandage.
Braden scale:
Sensory perception - 2
Moisture - 3
Activity - 1
Mobility - 1
Nutrition - 1
Friction and shear - 1
= 9 high risk for impaired tissue integrity and pressure ulcers
CARDIOVASCULAR: S1 and S2 audible. Rhythm is regular. No carotid bruit. Palpable radial
pulses (+2). Palpable DP pulses (+2)
HEENT: No nasal drainage. No discharge from eyes. Gums are pink. Mouth is moist.
Pulmonary: Lungs are clear in all lobes. 1 mediastinal and 1 pleural chest tube draining
serosanguineous fluid to suction 120mL in 8 hours (day after surgery). Nasotracheal suctioning
performed twice, serosanguineous drainage)
GI: Active bowel sounds. Passed soft-formed brown stool
GU: UTI-treated with cipro, foley catheter removed, incontinent. Urine was cloudy, light yellow
in the foley bag, prior to foley being removed. After foley catheter was removed the urine was
clear yellow.
IV Assess: L forearm IV saline lock is patent, clean, and intact. Right hand IV is patent, clean,
intact, and infusing. SWAN-Ganz patent, clean, and intact.
DVT prophylaxis- sequential boots and heparin administration. The heparin administration was
stopped for 24 hours post intraarterial tPA.
Activity: The patient was able to swallow two bites of jello, but unable to swallow oral
medications. PT was consulted, camed and did ROM exercises with the patient. I dont know if a
dietitian was consulted.
Psychosocial/Spiritual: The patient is able to understand to some degree what is going on
around her. The patient can hear and take in her surroundings. It is important that nurses and

Natalie Williams

11

other health care workers continue to talk to her and communicate therapeutically. The patients
spouse comes in and visits during the day for a few hours. Religious beliefs not discussed at this
time.
Educational Needs: At this point in time the teaching that was done with the patient consisted
of making the patient aware of where she was, what her situation was, and what is being done for
her. The teaching was limited due to the patients decreased LOC and mental status. If patient
condition improves, the patient may need teaching on how to control blood sugars, since the
HbA1c was abnormal. Speak with husband about home medications and the patients adherence
to medication regimen. Patient smoked for 11 years, but has quit. Ask spouse if he is a smoker.
Obtain information about alcohol consumption.

Medications:
Medication

Indication

Dose/Route/
Frequency

Side
Effect/Contraind
ications

Patient
Correlation

Natalie Williams

Ferrous Sulfate

12

Ferrous sulfate
provides the iron
needed by the
body to produce
red blood cells.
It is used to treat
or prevent irondeficiency
anemia, a
condition that
occurs when the
body has too few
red blood cells
because of
pregnancy, poor
diet, excess
bleeding, or
other medical
problems.

325mg/PO/BID

D5/.45NS W/20
MeQ KCL
Parenteral
solution

Given for
hydration,
electrolyte
balance, and
balance of
glucose

1000mL/IV/
60mL/hr

NaCl 0.9%
Parenteral
solution

Maintenance of
fluid and
electrolyte status

1000mL IV
q24hrs

Not given,
patient unable to
take oral pills.

Side Effects:
Constipation,
upset stomach,
black stools,
temporary
staining of teeth.
Contraindicated:
Diverticular
Disease, Ulcer
from Stomach
Acid, Ulcerated
Colon,
Inflammation of
the Lining of the
Stomach and
Intestines,
Several Blood
Transfusions,
Problems with
Food Passing
Through the
Esophagus, Iron
Metabolism
Disorder causing
Increased Iron
Storage,
Increased Bodily
Iron from High
Red Blood Cell
Destruction,
Hemolytic
Anemia

Given

Iron deficiency
anemia. Hgb is
8.8 post surgery,
this level is low,
but not low
enough to get
packed RBCs.
The patient cant
take the ferrous
sulfate because
she is unable to
swallow pills.

SE: arrhythmias,
abd pain,
weakness,
restlessness,
parasthesia

Hydration and
electrolyte
balance

Side effects:
CHF, pulmonary
edema, edema,
hypokalemia,

Pt was receiving
medications
through his IV.
He was also
maintaining

Natalie Williams

13

Heparin
5,000unit/1mL
parenteral
solution

AnticoagulantPost-surgical
prophylaxis for
blood clots.
Works by
decreasing the
clotting ability
of the blood.

1mL q12hrs SQ

Dobutamine in
D5W

Dobutamine is
an inotropic
agent. It works
by increasing the
strength and
force of the
heartbeat,
causing more
blood to
circulate through
the body.
Nitrates: Treats
or prevents chest
pain in people
with CAD.
Nitroglycerin is
in a class of
medications
called
vasodilators. It
works by
relaxing the
blood vessels so
the heart does
not need to work
as hard and

500mg/250mL
IV titrate

Nitroglycerin in
D5W
25mg/250mL

PTT 65s

Not given due to

increased heart
rate.

25mg/250mL IV
titrate 50
mcg/min

hypernatremia,
hypervolemia
Contraindicated:
fluid retention,
hypervolemia
Caution in
fluid/electrolyte
imbalances
Nausea,
vomiting,
bloody vomit,
blood in urine,
increased risk of
bruising.
Contraindicated:
severe
thrombocytopeni
a, uncontrollable
active bleeding.
Side effects:
Increased heart
rate, increased
blood pressure,
headache,
nausea
Contraindicated:
digoxin,
metoprolol

fluid status due

to no oral intake.

Side effects:
flushing, lightheadedness,
dizziness
Contraindicated:
in patients with
early myocardial
infarction,
severe anemia,
increased
intracranial
pressure, and
those with a
known
hypersensitivity

Hx: of angina,
was not on
medication
during time in
ICU

To prevent postoperative blood

clots.

Perfusion of
vital organs,
specifically the
brain

Natalie Williams

14

therefore does
not need as
much oxygen.
Nitroprusside
(nipride)
25mg/mL
solution

Nitroprusside is
a vasodilator
that works by

to nitroglycerin.
100mg/4mL IV
titrate
Not given

relaxing the
muscles in your
blood vessels to
help them dilate
(widen). This
lowers blood
pressure and
allows blood to
flow more easily
through your
veins and
arteries.
Nitroprusside is
used to treat
congestive heart
failure and lifethreatening high
blood pressure
(hypertension).
KCL
20MEQ/100mL

Give if K level
is <3.7

20MEQ/
100mL IVPB
PRN infuse over
2hrs
Not given

Side Effects:
tachycardia,
hypotension,
cyanide toxicity
Contraindicated:
Sodium
nitroprusside
should not be
used to produce
hypotension
during surgery
in patients with
known
inadequate
cerebral
circulation.
Sodium
nitroprusside
should not be
used for the
treatment of
acute congestive
heart failure
associated with
reduced
peripheral
vascular
resistance such
as high-output
heart failure that
may be seen in
endotoxic sepsis.
Side effects:
vomiting,
arrhythmias,
muscle
weakness
Contraindicated:
Potassium
supplements are
contraindicated
in patients with
hyperkalemia

Relaxes the
constricted
blood vessels
and allows for
increased
perfusion, while
decreasing blood
pressure.

Prevent
arrhythmias,
electrolyte
disturbance,
hypokalemia

Natalie Williams

15

Magnesium
Sulfate
1gm/2mL
solution

Give if Mg
levels is <2.0

Regular insulin

Treat Diabetes
Mellitus type II.
Start if BS 130+
and titrate to
maintain blood
sugar 90-130 per

2gm/4mL IV
PRN/Infuse over
2hrs
Not given

50unit/0.5mL IV
titrate
Infusion rate =
blood glucose
level/100

since a further
increase in
serum potassium
concentration in
such patients can
produce cardiac
arrest.
Hyperkalemia
may complicate
any of the
following
conditions:
chronic renal
failure, systemic
acidosis such as
diabetic
acidosis,acute
dehydration,
extensive tissue
breakdown as in
severe burns,
adrenal
insufficiency or
the
administration of
a potassiumsparing diuretic
Side effects:
hypomagnesemi
a
Decreased
deep tendon
reflexes,
diarrhea,
muscle
weakness, AT
EXTREMELY
HIGH levels

hypotension
Contraindicated:
Side effects:
hypoglycemia,
H/A, hunger,
dizziness
Contraindicated:
hypoglycemia

Hyperglycemia

Natalie Williams

16

open-heart
protocol

Blood glucose =
209
Given 2units/hr

Aspirin Enteric
(ecotrin)

Prophylaxis of
TIA.

325mg (E.C.)
tablet PO once
daily
Not given

Famotidine
(pepcid)

Acetaminophen
(Tylenol)

histamine-2
blockers, works
by decreasing
the amount of
acid the stomach
produces.
Prevention of
stress-induced
upper GI bleed
in critically ill
patients.
For H/A or rectal
temp >100

20mg/2mL IV
once daily 2100

650mg/2
tablet/PO/q4hrs
PRN
Not given

Onadestron
(Zofran)

nausea/
vomiting

4mg/2mL IV
q4hrs PRN
Not given

Bisacodyl
(dulcolax)

Constipation

5mg tablet
(E.C.) PO BID
PRN

Use Cautiously
in: stress and
infection,
hepatic/renal
impairment
Side effects:
hemorrhagic
stroke, GI bleed,
tinnitus
Contraindicated:
thrombocytopeni
a
Use cautiously
in: severe
renal/hepatic
disease and
cardiovascular
disease
Side effects:
headache,
dizziness,
diarrhea
Contraindicated:
renal impairment

Side effects:
hepatotoxicity,
increased liver
enzymes
Contraindicated:
severe hepatic
impairment
Side effects:
diarrhea,
headache, fever,
lightheadedness
Contraindicated:
concomitant use
of apomorphine
Side effects: abd
cramps, nausea,
throat irritation

Used to prevent
ischemic stroke,
chest pain, and
heart attack

Prevention of
stomach ulcer

Given for nausea

and vomiting
when the patient
was first taken
off of the
ventilator
Taken for
constipation
prior to stroke.

Natalie Williams

17

Not given

Bisacodyl
(dulcolax)

Constipation

10mg rectal
suppository BID
PRN
Did not receive

Morphine

Opioid analgesic

2-4mg q 3-4 hrs

IV PRN
2mg given at
9am
2 more mg given
3 hours later at
12pm

Norco
(hydrocodoneacetaminophen)

Opioid analgesic

Dexmedetomidi
ne (precedex) in
NS 0.9%

General
anesthesia and
sedation

Contraindicated:
Symptoms
associated with
acute abdominal
problem
Side effects: abd
cramps, nausea,
throat irritation
Contraindicated:
Symptoms
associated with
acute abdominal
problem
Side effects:
cramps,
difficulty having
a BM,
drowsiness,
weight loss
Contraindicated:
respiratory
depression,
hypercarbia

Patient indicated
desire to receive
pain medications
by nodding
head.
5-325mg tablet 2 Side effects:
tablets PO q3hrs anxiety,
PRN
dizziness,
nausea, blurred
Not given
vision
Contraindicated:
abnormal heart
rhythm,
abnormally low
blood pressure,
kidney
problems,
increased
intracranial
pressure
(0.3mcg/kg)
Side effects:
(200mcg/50mL) hypotension,
(0.2bradycardia,

Did not receive

Pain at incision
site, pain
associated with
open-heart
surgery.

The patient did

not take any
norco while I
was on the unit,
unable to
swallow pills.

For sedation of
initial intubation
and mechanical

Natalie Williams

18

0.7mcg/kg/hr) =
8mL/hr

Propofol
(diprivan)

General
anesthesia and
sedation

Given in the
operating room
(5-50
mcg/kg/min)
(10mg/1mL IV
titrate) (20mcg)
= 9.4ml/hr
Given in the
operating room

Phenylephrine
HCL (neosynephrine)

Alpha agonist
vasopressor to
treat
hypotension

40-180mcg/min
20mg/mL IV
titrate
Not given
because systolic
blood pressure
was above 90
and the heart
rate was
tachycardic.

sinus arrest
Contraindicated:
renal failure,
liver failure

ventilation

Side effects:
apnea,
bradycardia,
hypotension,
burning/stinging
at IV site,
involuntary
muscle
movements.
Contraindicated:
hypersensitivity
to soybean oil,
egg lecithin,
glycerol
Caution in CV
disease, lipid
disorders,
geriatric,
debilitated,
hypovelmia

On sedation
when intubated
and on vent.

Side effects:
extravasation,
HTN, decrease
UO, pulmonary
edema,
bradycardia,
metabolic
acidosis.
Contraindicated:
glaucoma, HTN,
v-tach

Titrate to keep
SBP > 90
Increases
peripheral
vascular
resistance and
BP while
lowering CO
and renal
perfusion. The pt
is on this med
because his BPs
were running
low and
Propofol
potentiates low
BP. The
medication was

Natalie Williams

19

stopped because
the heart race
was tachycardic.
Mg Hydroxide
suspension (milk
of magnesia)

Constipation

Nystatin Powder

Nystatin powder
is an antifungal.
It works by
weakening cell
membranes of
the sensitive
fungus.
Beta-blocker,
treats high blood
pressure, works
by blocking
alpha and beta
receptors in the
body, which
lowers blood
pressure.

Labetalol
(trandate)

niCARdipine
(cardene)

30mL PO every
day PRN

Side effects:
nausea, diarrhea,
and headaches
Contraindicated:
Hemorrhoids,
Impacted Stool,
Stomach or
Intestine
Blockage,
Incomplete or
Infrequent
Bowel
Movements,
Kidney Disease,
Diarrhea,
Aluminum
Poisoning,
Chronic
Diarrhea, Low
Amount of
Phosphate in the
Blood
Apply topically
Side effects:
once a day/For
allergic reaction
external use only Contraindicated:
allergy.

Was not given

20mg/4mL IV
PRN

If SBP >
185/DBP >110:
give over 1-2
minutes

Not given

Calcium-channel 40mg/200mL IV
blocker, used to start at 5mg/hr

Side effects:
dizziness,
headache,
hypotension
Contraindicated:
cardiac failure,
cardiogenic
shock,
prolonged and
severe
hypotension
Side effects:
chest pain,

Given for yeast

infection in
groin

Titrate to keep
SBP <

Natalie Williams

Oxygen

20

treat high blood

pressure, it
relaxes your
blood vessels so
your
O2 assistance

and increase by
2.5mg/hr MAX
dose is 15mg/hr
Not given
2L per NC prn
Given

Albuterol sulfate

Beta2-adrenergic
agonist

nausea,
palpitations,
SOB, headache
Contraindicated:
aortic stenosis
Side effects:
irritation of
nares from NC

2.5mg/3mL nebu Side effects:

q6 PRN
tremors, chest
pain,
Given by
bronchospasm
respiratory
Use Caution: if
therapy
Hx of
hypertension,
coronary
insufficiency,
can aggravate
diabetes

185/DBP<110

Patient needed
supplemental
oxygen in order
to keep oxygen
saturation within
a normal range.
As needed for
shortness of
breath/wheezing

Prevention/Plan:
Prevention of this admission: The client may have been able to prevent this admission if she
had better control of her blood sugar, diabetes increases the risk for CAD. Smoking increased her
risk for CAD. If the patient was eating a diet high in saturated fats and high in cholesterol this
could have increased her risk for CAD.
Prevent further admissions: By following a heart healthy and diabetic diet, not smoking,
checking blood sugars, administering insulin, and exercising the patient will be able to prevent
further complications with her heart.
Type II diabetes management- Monitor blood sugar as prescribed. Diet of
vegetables, whole grains, fruits, non-fat dairy products, beans, lean meats, poultry, fish.
Patient could talk with a dietitian to get more information about a proper diabetic diet.
The patient is on insulin to control blood sugar. The medication should be reviewed with
the patient and the patient should be taught when to take the medication and how much.
Teach patient to recognize the symptoms of hypoglycemia and hyperglycemia.
Medication adherence- teach patient about importance of adhering to medication
regimen. Develop a plan that will make it easier for patient to take medications. Talk with
patient about insurance and financial ability to get medications.

Natalie Williams

21

Priority NANDAs, NICs, and NOCs

NANDA: Tissue integrity, risk for impaired related to: impaired physical mobility, nutritional
deficit,
NIC: turn patient q2hours. Cleanse, monitor, and promote healing of incision. Application of
topical substances or manipulation of devices to promote skin integrity and minimize skin
breakdown. Apply nystatin powder.
NOC: the patient will have a braden score greater than 20. No signs or symptoms of infection,
necrosis or lesions. Structural intactness and normal physiologic function of the skin.
NANDA: Communication: verbal, impaired related to: CVA that caused aphasia
NIC: Speech pathology consult. Work with patient to communicate by nodding or shaking head.
Attending closely to and attaching significance to the patients nonverbal messages.
NOC: expression of meaningful verbal and/or nonverbal messages. Reception and interpretation
of verbal and/or nonverbal messages. The patient will communicate needs to staff and family
with minimal frustration. Communication satisfaction with alternative means of communication.
NANDA: Airway clearance, ineffective related to: inability to cough, difficulty taking deep
breaths, inability to use inspiratory spirometry, whistling noise on expiration (adventitious breath
sounds)
NIC: airway suctioning, prevention or minimization of risk factors for aspiration. Cough
enhancement by encouraging deep inhalation and forceful expulsion of air.
NOC: patient has no adventitious breath sounds, the patient is able to cough and clear secretions
NANDA: Ineffective breathing pattern related to: A. decreased rate and depth of respirations
associated with the depressant effect of anesthesia and narcotics. B. diminished lung/chest wall
expansion associated with weakness, fatigue, reluctance to breathe deeply because of chest
incision and fear of dislodging chest tube.
NIC: assess for and report signs and symptoms of impaired respiratory function: dyspnea, rapid,
shallow or slow respirations, use of accessory muscles, adventitious breath sounds
NOC: Demonstrate a breathing pattern that supports blood gas results with in the clients normal
parameters.