Hi, shrgawia!
I'm assuming this is a case study and that this is not a real patient that you have taken care of. If that is the case, then what you need to do is look up the signs and symptoms of the six medical conditions that this patient has.
- Ischemic Heart Disease
- Congestive Heart Failure
- Pulmonary Edema
- Aspiration Pneumonia
- History of MI with poor ejection fraction
- Acute Respiratory Failure
If you take the time to look up and read about the conditions this patient has, you will see that they are related. You will often see some of these same conditions existing together in patients.
Step #1 of the care planning process is the collection of data about the patient. If this were a real patient you would use information from the patient's medical record as well as the information you gathered from your own assessment of the patient. However, not having that, you must rely on textbook descriptions of the conditions you have been told that the patient has.
Signs and symptoms of
Ischemic Heart Disease (IHD) are substernal chest pain, exertional chest pain, chest pain relieved with rest, palpitations, shortness of breath, and cough. If it progresses to acute coronary syndrome then there will be hypotension, development of rales in the lung, S3 gallop rhythm, and onset of jugular vein distention.
Signs and symptoms of
left-sided heart failure which is generally the cause of congestive heart failure are dyspnea, non-productive cough, crackles in lungs, hemoptysis, tachycardia, development of S3 and S4 heart sounds and cool, pale skin.
Signs and symptoms of
pulmonary edema are dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, cough, mild tachypnea, elevated blood pressure, crackles in bases of lungs, jugular vein distension, and tachycardia. Eventually the patient will develop labored, rapid breathing, increased lung congestion, production of frothy, bloody sputum, arrhythmias, thready pulse, cold and clammy skin, diaphoresis, cyanosis and hypotension.
Signs and symptoms of
aspiration pneumonia are low grade fever, weight loss, productive cough with foul smelling sputum, an ill appearing patient, dyspnea, tachypnea, tachycardia, rales, diminished breath sounds, bronchial breath sounds, dullness to percussion, tactile fremitus, and egophony.
Acute respiratory failure is often associated with asthma, chronic obstructive pulmonary disease, pneumonia, pneumothorax, pulmonary embolism, pulmonary edema and interstitial lung disease. Signs and symptoms of acute respiratory failure are hypoxemia, a low PaCO2, a low PaO2. Supplemental oxygen may not help.
A myocardial infarction often leaves the patient with permanent damage to the heart. These patients may have to be regularly monitored and treated for congestive heart failure, hypertension, chest pain, arrhythmias, and major depression. In addition, they will often be placed on anticoagulant therapy and anti-lipidemics. If they are on anticoagulants they will be in danger of potential injury due to accidental hemorrhage. With a compromised ejection fraction they may have a pacemaker and/or implanted defibrillator. I am mentioning these because there would be a great deal of patient teaching involved regarding the taking of these medications or the operation of a pacemaker or an implanted defibrillator.
In step #2 of the care planning process, you will use the signs and symptoms to determine what nursing diagnoses to use. You are going to notice that many of the signs and symptoms of this patient's 6 medical conditions are repeated. This patient will have a great many respiratory problems. The symptoms that I would work with to form nursing diagnoses are:
- chest pain
- chest pain relieved with rest
- palpitations
- dyspnea (shortness of breath)
- paroxysmal nocturnal dyspnea
- orthopnea
- tachypnea
- cyanosis
- hypoxia
- cough (productive and nonproductive)
- foul smelling sputum
- rales, crackles
- diminished breath sounds
- S3 gallop and S4 heart sounds
- jugular vein distention
- hypotension
- tachycardia
- arrhythmias
- decreased injection fraction
- cool, pale skin
- cold and clammy skin
- diaphoresis
- low grade fever
- verbal expressions of having no control over the outcome of the disease processes going on
These symptoms, or defining characteristics, become the basis and reasoning that supports choosing each particular nursing diagnoses. You will form nursing diagnostic statements that usually consist of three parts (although you should do what your nursing instructors have told you to do and I will construct 3-part nursing diagnostic statements for you from the symptoms) and place them in order of priority according to Maslow's Hierarchy of Needs. These statements have 3 elements:
- The P (problem) which is the actual nursing diagnosis
- The E (etiology) which is the cause of the problem
- The S (symptoms) or defining characteristics which are associated with the problem
NANDA (North American Nursing Diagnosis Association) has specified the exact language that is to be used for 172 nursing diagnoses. They have also defined each nursing diagnosis. Each nursing diagnosis has a specified list of defining characteristics (symptoms) and related factors (causes or etiologies) which are very helpful to use when determining which nursing diagnoses will be appropriate to use. R/T stands for "related to" and AEB stands for "as evidenced by".
- Impaired Gas Exchange R/T fluid in lung tissue and alveoli AEB hypoxia, cyanosis, tachypnea, dyspnea, tachycardia, cool and pale skin, diaphoresis
- Ineffective Airway Clearance R/T retained secretions and infection secondary to aspiration pneumonia AEB dyspnea, orthopnea, diminished breath sounds, nonproductive cough, rales, crackles and cyanosis
- Decreased Cardiac Output R/T altered contractility, altered preload, ventricular ischemia and altered heart rate AEB tachycardia, palpitations, jugular vein distention, cold and clammy skin, dyspnea, crackles, cough, orthopnea, paroxysmal nocturnal dyspnea, decreased ejection fraction, presence of S3 and S4 heart sounds, hypotension, and arrhythmias
- Hyperthermia R/T infectious process secondary to aspiration pneumonia AEB tachycardia, low grade fever and foul smelling sputum
- Acute Pain R/T cardiac ischemia AEB chest pain with activity and/or unrelieved by rest
- Powerlessness R/T feeling helpless secondary to major depression AEB verbal expressions of having no control over the outcome of the disease processes going on
There may be other nursing diagnoses that could be used, but these would be the primary ones that address the major symptoms. Also, because we have no data as to how the patient is able to carry out his activities of daily living, the nursing diagnoses that address those things cannot be extrapolated at this time.
You can get more information about how the nursing process works at these two threads on the nursing student forums here on allnurses:
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