Running head: PLAN OF CARE FOR PATIENT AG 1

Plan of Care for patient AG

Kerene Phillips-Ross

Delaware Technical Community College

NUR 320
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Plan of Care for patient AG

Nursing Assessment

Patient AG is a 32 year old African American female. She works 40 hours per week as a

manager at a prestigious IT company. She is a single mother, with 2 teenage girls. She also takes

care of her elderly mother, which makes her apart of the sandwich generation.

She presented in the ED with complaints of rapid heart rate. Upon assessment Pt.s vital

signs were as follows: T 98.2, R 20, HR 118, BP 86/48, Pt. reported a pain level of 0/10. Pt. had

urinary output of 21ml/hr. Pt. also reported that she felt as if her heart was beating out of her

chest. Decreased cardiac output was chosen for her number 1 nursing diagnosis related to her

decreased BP and her increased HR. My goals for this patient were to decrease her heart rate and

increase her BP to her baseline. Another goal was to maintain Cardiac output of 5 to 6 liters per

minute at rest. My interventions were to get an EKG to rule out abnormalities, encourage PO

fluids, and administer intravenous fluids and anxiolytics as ordered. My Pt. was very anxious, so

I created a calming environment to promote relaxation. I also did deep breathing and relaxation

exercises with my Pt to reduce her anxiety. Researchers have documented the benefits of a

regular practice of simple, deep breathing (1,2,6), which includes: reduced anxiety and

depression, lower/stabilized blood pressure, increased energy levels, muscle relaxation,

decreased feelings of stress and overwhelm (Patal, ND). The desired outcome was for my

patients BP and HR to be within normal limits and to reduce her anxiety.

After talking to my patient a while longer, I discovered that she works at a cubicle and

does not get much exercise. The second nursing diagnosis of sedentary lifestyle related to work

conditions was chosen. I educated my patient on how detrimental a sedentary lifestyle is to

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overall health and wellbeing. Studies show that Physical inactivity is the fourth leading cause of

death worldwide.[34] It is estimated that over a third of cancers and about 80.0% of heart

disease, stroke and type 2 diabetes could be prevented by eliminating behavioral risk factors such

as physical inactivity, unhealthy diet, tobacco smoking, and alcohol use ( Mckenney ,2016)The

expected goal for my patient is to increase activity during work hours and to start an exercise

regimen outside of work. First I educated my patient on the importance of physical activity

because I know that would benefit not only her physical wellbeing but also her emotional

wellbeing.

After spending much time talking with my patient using therapeutic communication we

build a rapport. My patient informed me that she has been having increased anxiety due to recent

multiple losses. She stated that she has been spending a lot of time drinking alone and thinking

about all my problems .I cant figure out how to get past this. Ive even started smoking weed

again. My third nursing diagnosis is ineffective individual coping strategies, related to Pt.

having difficulty using adaptive behaviors and positive problem solving techniques. The goal for

my patient is to learn and use positive coping skills and find a positive outlet for stress. Some

interventions used were educating Pt. on how to use positive coping skills and problem solving

techniques to deal with every day stressors. I also recommend peer support groups in her

community for those coping with anxiety and depression. Peer support is delivered in a variety

of modalities, including, but not limited to, in-person self-help groups, Internet support groups,

peer run or operated services, peer partnerships, peers in health care settings who serve as peer

advocates, peer specialists, and peer case managers (Tracy & Wallace, 2016)
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References

Patel, S. (2017, April 19). Breathing for Life: The Mind-Body Healing Benefits of Pranayama.
Retrieved April 26, 2017, from http://www.chopra.com/articles/breathing-for-life-the-mind-body-
healing-benefits-of-pranayama

Tracy, K., & Wallace, S. P. (2016, September 29). Benefits of peer support groups in the treatment of
addiction. Retrieved April 27, 2017, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5047716/

James, J. (2016, April 3). The health benefits of physical activity and cardiorespiratory fitness.
Retrieved April 27, 2017, from http://www.bcmj.org/articles/health-benefits-physical-activity-and-
cardiorespiratory-fitness