[newstart08]

Help, Help, Help.
I just started my LVN-RN transition program a few weeks ago. I have been in school for 11 years, and I never actually did care plans in my real world experiences of being an LVN.

I am doing a "Concept Map." Heres the scenario.

A 60 y.o. female with a hx of ASHD and HTN. Borught to the ED by ambulance. She is c/o nausea, anorexia, blurred vision. She is alert and orientated; although her daughter states that she has had periods of confusion over the last several days. The client explains that she is currently under her MD's care for episodes of atrial fibrillation and atrial flutter that began about 1 week ago. Home meds include: Digoxin 0.125 mg daily, as well as Quinidine Sulfarte and Catapress. The cardiac monitor reveals atrila fibrillation with a ventricular rate of 180 bpm.

I need 3 nursing dx with R/T and AEB.

I have come up with Decreased Cardiac output, r/t altered rate and rhythm, AEB atrial dysrythmia and ventricular rate of 180 bpm.

Is this written correctly, and what else can I use.

Please help, and thanks in advance

[Daytonite]

Hi, newstart08!

First of all, congratulations on starting your RN bridge program.

Secondly, to start you off with this whole process of care planning I'm going to give you the links to three "sticky" threads on nursing student forums that you should read over when you get a chance because most of the information I tell students about care plans is repeated there and you can find it very conveniently

• http://allnurses.com/forums/f205/desperately-need-help-careplans-170689.html - Desperately need help with careplans (in Nursing Student Assistance Forum)
• http://allnurses.com/forums/f50/careplans-help-please-r-t-aeb-121128-7.html - CAREPLANS HELP PLEASE! (with the R\T and AEB) (in General Nursing Student Discussion Forum)
• http://allnurses.com/forums/f205/care-maps-225330.html - Care Maps (in Nursing Student Assistance Forum)

Care plans, no matter in what format they are eventually committed to paper, follow the nursing process. If you don't learn another thing from your RN program, this is the one concept that you MUST learn:

THE STEPS OF THE NURSING PROCESS (WRITTEN CARE PLAN)

1. Assessment (collect data)
2. Nursing Diagnosis (group your assessment data, shop and match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnosis to use)
3. Planning (write measurable goals/outcomes and nursing interventions)
4. Implementation (initiate the care plan)
5. Evaluation (determine if goals/outcomes have been met)

Before you can even decide on any nursing diagnoses you need to go through Step #1 which is collect your assessment data:

A 60 y.o. female with a hx of ASHD and HTN. Brought to the ED by ambulance. She is c/o nausea, anorexia, blurred vision. She is alert and orientated; although her daughter states that she has had periods of confusion over the last several days. The client explains that she is currently under her MD's care for episodes of atrial fibrillation and atrial flutter that began about 1 week ago. Home meds include: Digoxin 0.125 mg daily, as well as Quinidine Sulfate and Catapress. The cardiac monitor reveals atrial fibrillation with a ventricular rate of 180 bpm.

I've colored and highlighted the abnormal assessment data. It is the abnormal assessment data that becomes the most important in determining the nursing diagnoses you will use--NOT THE MEDICAL DIAGNOSIS. The medical diagnoses become important in your critical thinking process and looking at the underlying pathophysiology of what might be going on with your patient, but does not particularly affect your choice of nursing diagnoses. You need to do a little investigatory work here first. If this were a real patient I would advise you to look up the signs and symptoms of ASHD, HTN, atrial fibrillation and atrial flutter to see if you missed any of them when doing your patient's assessment. You should look them up now anyway to learn about them and to confirm what I'm about to tell you. Also, look up these three drugs, what they are for and their side effects.

• the blurred vision may be a symptom of her hypertension
• a complication of atrial fibrillation is TIAs and strokes
  • symptoms of a stroke can include a change in the person' level of consciousness and sensory losses (as in visual disturbances)
• nausea can occur with a lot of conditions but to keep to the scenario at hand, it occurs in arrhythmias, right sided heart failure (why is this patient on Digoxin?), myocardial infarctions and as a side effect of some medications (Catapres?)
• one of the things that is happening when a heart is in tachycardia (the heart rate of 180) is that the heart is attempting to get more oxygen to the body's tissues. Because each of these beats contains less blood than normal. Less blood=less oxygen going to the tissues. The affect of this is that it decreases cardiac output (less blood being pumped) and, therefore, cardiac and peripheral perfusion (less oxygen) with the resulting symptoms of dizziness and decreased levels of consciousness (perfusion to the brain)
• anorexia can be a side effect of drug therapy
• sometimes you won't be able to discover why the patient is having the symptoms they are having because there is just not enough data.

So, the patient's symptoms that you have to work with are:

• tachycardia
• nausea
• blurred vision
• periods of confusion over the last several days

In Step #2 you want to match these abnormal assessment items to likely nursing diagnoses. This requires that you have some kind of NANDA reference to look at. It is important to be able to refer to the defining characteristics (symptoms) of each nursing diagnosis you are considering using. You also need to look at the definition of each nursing diagnosis you use because it tells you what the purpose is that the particular diagnosis is aiming to target as the patient's problem. A NANDA reference is also going to give you the related factors (you will call them R/T items in your nursing diagnostic statement) so you don't have to be trying to fathom these things out yourself. NANDA's already done it for you.

There are 4 potential nursing diagnoses here based solely on the information provided by the scenario. I am going to list them in order of priority (by Maslow's Hierarchy of Needs). Keep in mind that this is my interpretation of the scenario. Your instructor might have different ideas based of what you have been getting lectures over. If you are allowed to pull in information from investigating the signs and symptoms of ASHD, HTN, atrial fibrillation and atrial flutter there might be more nursing diagnoses and some of your nursing diagnostic statements would become greatly expanded with much more assessment data. I've also linked you to nursing diagnosis pages on some of the online care plan constructors so you can see the NANDA information as I'm seeing it from my reference books.

1. Decreased Cardiac Output R/T altered heart rate and rhythm AEB a ventricular heart rate of 180 beats per minute and atrial fibrillation Decreased Cardiac output http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=09
2. Nausea R/T drug therapy AEB patient report of nausea and anorexia Nausea
3. Disturbed Sensory Perception, visual R/T altered sensory reception AEB patient report of blurred vision Disturbed Sensory perception specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=46
4. Risk for Injury R/T tissue hypoxia and/or a side effect of medication [this covers the confusion] Risk for Injury

If you look at these diagnostic statements very carefully you will see that all the information that follows the "AEB" part of each statement is actually the abnormal assessment information that I highlighted in red from your original scenario. When you move on to Step #3 which is to write measurable goals/outcomes and nursing interventions, it is these abnormal assessment items that you address. You will also notice that the "R/T" part of each statement is an etiology, or what you best perceive to be the cause, of the patient's AEBs in keeping with the spirit of that nursing diagnosis.

Just so you don't think I'm pulling stuff out of a hat, here are the books I used to help me determine the above:

• NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008 published by NANDA International
• Nursing Diagnosis Handbook: A Guide to Planning Care, 7th Edition, by Betty J. Ackley and Gail B. Ladwig
• Signs & Symptoms: A 2-in-1 Reference for Nurses by Springhouse, Springhouse Publishing Company Staff
• 2007 Mosby's Nursing Drug Reference, 20th edition, from Mosby, Inc.

I wanted to make one comment. I know you posted this same question on another forum and someone responded to you with some possible nursing diagnoses to use. Specifically,

Decreased tissue perfusion R/T decreased cardiac output & AEB periods of confusion

is wrong, wrong, wrong.

1. The correct diagnosis is Ineffective Tissue Perfusion and it MUST be specified as to the system of the body involved Ineffective Tissue perfusion specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral
2. This diagnosis covers all tissues EXCEPT the heart specifically.
3. For decreased tissue perfusion of the heart itself you must use Decreased Cardiac Output.
4. If you refer to a NANDA reference or any careplan book that lists the related factors for this diagnosis of Ineffective Tissue Perfusion you will not find decreased cardiac output listed as a related cause. It is because decreased cardiac output has been put into it's own nursing diagnosis.

Where the perfusion and/or circulation of the heart, the organ, is the underlying problem you will ALWAYS, ALWAYS, ALWAYS use the nursing diagnosis of Decreased Cardiac Output. Therefore, it is imperative that you have a good understanding of the terms used by NANDA in this diagnosis: preload, afterload, conductility.

If you are still having trouble with this, let me know.

Welcome to allnurses!

[time2fly]

I'm not in nursing school yet (start in August) so this will probably seem like a stupid question, but why are nurses writing diagnosis? Isn't it the Doc's job to diagnose patients? I've seen tons of these threads, I don't understand them... I suppose I will in a couple of months but wow... I didn't realize that nursing was so in-depth.

[mysterious_one]

Originally Posted by time2fly

I'm not in nursing school yet (start in August) so this will probably seem like a stupid question, but why are nurses writing diagnosis? Isn't it the Doc's job to diagnose patients? I've seen tons of these threads, I don't understand them... I suppose I will in a couple of months but wow... I didn't realize that nursing was so in-depth.

Hi,
congrats on your acceptance to nursing school,
to answer your question: just as docs make a diagnosis first, in order to treat a patient ( give meds or do a surgery for ex.), we as nurses have to make our own diagnosis before we can decide what kind of nursingcare we give specifically to the patient. All together it will be a "Careplan" for this specific patient.

[newstart08]

Daytonite

Thanks for the incredible feedback. I honor your knowledge.

I still have a bit of confusion about the nursing process itself.
I guess what I am confused about is when I go to my Nursing Diagnosis Handbook. I am using Ackley/ Ladwig, "An Evidence-Based Guide to Planning Care," 8th Edition, I get hung up on the implementations and the Defining Characteristics as wel as Related Factors. Some time the Nursing Diagnosis itself seems to fit, but not the definining characteristics or related factors that the book has listed.

As an example:
Disturbed Sensory Perception, visual R/T alterod sensory perception AEB blurred vision.
This seems very appropriate.

But when I go to the planning sections, it seems that the interventions are more related to chronic issues and blindness. It seems to me that my patient scenario is more related to side effects of medications or immediate acute conditions, so I have a hard time making the whole picture fit.

Is it ok to plan my interventions around teaching the patient to monitor for side effects of medications, and knowing what to report to MD, as well as understanding rationale for taking meds. This would increase overall safety for the patient and help prevent side effects in the future.
Is this totally off base?

Thanks again for your feedback

[Daytonite]

Originally Posted by time2fly

I'm not in nursing school yet (start in August) so this will probably seem like a stupid question, but why are nurses writing diagnosis? Isn't it the Doc's job to diagnose patients? I've seen tons of these threads, I don't understand them... I suppose I will in a couple of months but wow... I didn't realize that nursing was so in-depth.

It's a fair question. Here's an answer for you, so you can tell it to some of your fellow students who will, no doubt, be asking the same thing when you are introduced to this subject at some point in your nursing education. You are also going to hear fellow students trash nursing diagnoses and care planning in the worst way when they aren't understanding it and their grades or their instructor's comments are reflecting that.

A diagnosis is defined as "a careful investigation of the facts to determine the nature of a thing; the decision or opinion resulting from such examination or investigation" (from my very old copy of Webster's New World Dictionary of the American Language, College Edition, 1966 [a year before I started college], page 403). All kinds of professions make "diagnoses" of problems. Other synonyms for the word diagnosis are analysis, explanation, conclusion, findings. It is commonly used in conjunction with the word medical, as in medical diagnosis, and this is how we commonly hear it. However, a mechanic diagnoses the problems with your broken car; a cosmetologist diagnoses why your hair extensions aren't staying attached like they are supposed to; a TV repairman diagnoses why your TV won't turn on when you press the "On" button.

More recently, the big mucky mucks in the nursing world felt that just like the medical community had its own medical terminology and medical jargon, so should the nursing community have it's own nursing terminology and nursing jargon. And, poof, we now have nursing diagnoses courtesy of NANDA-I (North American Nursing Diagnosis Association, International). One of their purposes in doing this was to give all nurses a standard language to use that we would all recognize and understand. There are also some very practical uses for nursing diagnosis that involve the billing and reimbursement functions so that the independent nurse practitioners can get paid for the services they perform.

Now, as you read the posts on the allnurses forums and hear talk among nurses you are going to be exposed to a lot of different feelings about NANDA, nursing diagnosis and nursing language. Try to keep an open and non-judgmental mind (Nursing 101). Everyone is entitled to their opinion. But, one fact has been looming out there. Nursing schools and nursing instructors are teaching this new standard nursing language. So, like it or not, at some point in your education you are most likely going to be exposed to it and probably be required to learn to work with it. You have the choice of digging your heels in and refusing to learn it at the risk of getting a failing grade, or learning it and maybe gaining some understanding about how critical thinking works in the process of making decisions about patient care.

[Daytonite]

Originally Posted by newstart08

I get hung up on the implementations and the Defining Characteristics as wel as Related Factors. Some time the Nursing Diagnosis itself seems to fit, but not the definining characteristics or related factors that the book has listed.

As an example:
Disturbed Sensory Perception, visual R/T alterod sensory perception AEB blurred vision.
This seems very appropriate.

But when I go to the planning sections, it seems that the interventions are more related to chronic issues and blindness. It seems to me that my patient scenario is more related to side effects of medications or immediate acute conditions, so I have a hard time making the whole picture fit.

Is it ok to plan my interventions around teaching the patient to monitor for side effects of medications, and knowing what to report to MD, as well as understanding rationale for taking meds. This would increase overall safety for the patient and help prevent side effects in the future.
Is this totally off base? NO

Keep in mind that your Ackley/Ladwig is a reference book, a starting point for you. It is not going to list every intervention that is possible. What it does have, however, is the same definition, related factors and defining characteristics that go with each particular NANDA diagnosis that I have listed in my little NANDA publication, NANDA-I Nursing Diagnoses: Definitions & Classification 2007-2008. They pay a royalty to NANDA in order to be able to publish those definitions, related factors and defining characteristics. There is no conceivable way in the world that they could print out all the potential nursing interventions that are possible because of the variation in the way abnormal symptoms are going to be presented by patients. This is why care plans are customized. There actually is a work from the University of Utah of NIC (Nursing Interventions Classification) where they have attempted to list all the possible nursing interventions that can be done. There is still always going to be the customizing factor, however, that has to take into account the patient's situation. And, there is no end of nursing theorists out there to tell us what other factors we need to take into account when assessing patients!

What you might do is go on the Internet (I like to start with the Medline Plus site http://www.medlineplus.gov/ and see what kind of resources they can link you in to for blindness or impaired visual acuity problems. You may need to do a little searching, but I'm betting there will be a couple of sites where either organizations, hospitals or doctors offer advice for safety issues related to vision acuity problems. Sometimes that's just the way you have to approach these kind of things. Nursing--gotta love it!

Nursing interventions can be divided into four types:

1. Assess/monitor/evaluate/observe (to evaluate the patient's condition)
2. Care/perform/provide/assist (performing actual patient care)
3. Teach/educate/instruct/supervise (educating patient or caregiver)
4. Manage/refer/contact/notify (managing the care on behalf of the patient or caregiver)

In some cases, your interventions will be to observe for specific signs and symptoms of the patient's condition worsening or improving. Some interventions are going to be ones of direct hands-on patient care. Still, others will involve teaching the patient about the side effects of their medications, the signs and symptoms of their disease getting worse, or how to do a procedure themselves. And, there may be other interventions that involve getting other healthcare personnel to become involved to see the patient and provide their expertise.

You asked, if it was OK to plan your interventions around teaching the patient to monitor for the side effects of their medications, what to report to the MD, and understanding the rationale for taking the medications. The answer is yes. These are perfectly appropriate interventions because they relate to both the defining characteristic (symptom) as well as the underlying etiology that was responsible for bringing about the defining characteristic (symptom).

[newstart08]

Thanks again, all of this has been extremely helpful. It took me 3 days to do this concept map, and I changed it probably 5 different times. Two nights in a row I was up until 2 am in the morning. I thought it would be easy, I was wrong. This is my first one, so I now it will get easire. Wow, welcome to nursing school, huh. I spent a lot of my time just researching the disease processes, that took a lot of my efforts up. I really did learn a lot though. I guess that is what it's all about. For anybody who wants to see my final "Concept Map," just let me know.
thanks
newstart08

[peridotgirl]

to answer your question, no. It isn't the doctor's job to write nursing diagnoses. Nurses are the one responsible for the nursing diagnosis. I believe the doctors make medical daignoses. And no, that was not a stupid question. Part of becoming a nurse is to ask questions even if they seem foolish. By the Way, I'm new to the site.

[newstart08]

Patient Scenario


60 year old woman with a history of Arteriosclerotic Heart Disease and hypertension is brought by ambulance to the Emergency Department. She is alert and orientated. Cardiac monitor reveals atrial fibrillation with a ventricular rate of 180 beats per minute.

Medical History-


60 y.o. female


VS- 90/60, 180, 24, 98.4


Arteriosclerotic heart disease (ASHD)


Hypertension


Currently under care by PMD for Atrial fibrillation and Flutter that began 1 week ago


Home meds-


Digoxin 0.125 mg daily


Quinidine Sulfate


Catapress

Associated / Expected Signs & Symptoms of Medical Diagnosis


Atrial Fibrillation /Hypertension /Arteriosclerotic Heart Disease

Hypotension Shortness of Breath Chest Pain Weakness Chest pressure Dizziness
Racing Feeling Fatigue Distended Neck Veins
Sweating Anxiety *Nausea
*Anorexia *Blurred Vision *Periods of Confusion
Bradycardia Vomiting Lightheadedness
*Dysrhythmia *Tachycardia *Visual disturbances
Headache Fatigue





Nursing Diagnosis #1:

Decreased Cardiac Output, R/T altered heart rate and rhythm, AEB atrial dysrhythmia and ventricular rate of 180 beats per minute.

Nursing Goals:

Short term- Cardiac pump effectiveness as evidenced by blood pressure and pulse rate and rhythm within normal parameters for patient, by end of shift.
Long term- Ability to tolerate activity without symptoms of dyspnea, syncope or chest
pain by time of discharge.

Optional Functioning Outcome / Patient Perspective:


“I would like to be able to continue my daily walks with my dog.”

Nursing Interventions and Rationales:

Monitor ECG-


Monitor rate and rhythm and report trends and changes, monitor effectiveness of medications used to treat the dysrhythmia and tachycardia.


Establish and maintain intravenous access-


IV access is needed to provide Intravenous rate controlling agents and emergency medications


Monitor patient for symptoms of heart failure and decreased cardiac output, listen to heart sounds, lung sounds; note symptoms such as dyspnea, fatigue, weakness, crackles in lungs-


Assesses patient for major criteria of heart failure


Assess apical and peripheral pulses-


Evaluation for pulse deficit which signifies low cardiac output.


Monitor vital signs frequently-


To record trends in vital signs and to report changes


Apply oxygen and monitor oxygen saturation-


Oxygen supplementation is needed to enhance oxygen delivery when cardiac output is insufficient


Monitor laboratory values and report abnormal values-


CBC, Electrolytes, Cardiac enzymes, Digitalis level, PT/PTT, Chemistry; all should be evaluated and abnormalities noted and reported


Monitor Intake and Output hourly-


Decreased cardiac output results in decreased perfusion of the kidney, with a resulting decrease in urine output

Nursing Diagnosis #2:


Nausea, R/T pharmaceuticals and/or disease process, AEB reports of nausea and anorexia.

Nursing Goals:

Short term goal- Patient will be free from GI disturbances of nausea and anorexia by end of shift.
Long term goal- Patient will be able to verbalize understanding of drug therapy by stating drug actions, dosage regimen, pulse taking, reportable signs and follow up plans by time of discharge.

Optional Functioning Outcome / Patient Perspective


“I need to know what’s going on with my body and what to


watch for with all these new medications.”

Nursing Interventions and Rationale:

Determine cause of Nausea and Anorexia-


Identification of cause can lead to proper treatment.


Apply cold washcloth to forehead-


Distraction and comfort technique


Monitor electrolytes-


Imbalances may cause or be caused by nausea and vomiting


Instruct patient on drug actions for Digoxin, Quinidine Sulfate and Catapress-


Allows patient to gain further knowledge of therapeutic regimen for Atrial Fibrillation and Hypertension


Teach patient to take pulse rate before taking each dose of Digoxin-


Patient will gain understanding of proper technique and will understand not to take Digoxin if pulse rate is below 60 bpm.


Teach patient signs and symptoms of Digoxin Toxicity-


Pt will gain understanding of reportable symptoms which include; bradycardia, nausea, vomiting, anorexia, diarrhea, confusion, tachycardia, headache, fatigue, blurred or colored vision and dysrhythmias.


Teach patient to take medications at same time each day-


Establishes a routine


Teach patient not to take Digoxin at the same time as antacids or laxatives-


May decrease Digoxin absorption


Teach patient to report for scheduled laboratory tests & follow up MD visits


Digoxin levels and electrolytes need to be monitored for safe and therapeutic levels. Stresses importance of continued care.

Nursing Diagnosis #3:


Risk for injury, R/T sensory dysfunction, AEB reports of blurred vision and periods of confusion.

Nursing Goals:

Short term goal- Pt will be free of harm and injury during this shift.
Long term goal- Actions will be taken to ensure safety in home environment with
access to family support as needed, by time of discharge.

Optional Functioning Outcome / Patient Perspective


“I am very independent and until lately sharp as a tack,


I do not want to lose my independence.”

Nursing Interventions and Rationale:

Determine fall risk by using evaluation screening tool-


Determines patients actual risk of falls and establishes a pattern of communicating such risk among staff members and family.


Attend to one task at a time-


Due to patients reports of blurred vision and periods of confusion, patient has multiple risks identified for injuries and falls. Attending to one task at a time will decrease patients risk for fall.


Identify cause of confusion and blurred vision-


Symptoms may be related to pharmaceuticals or disease process. Identifying cause will ensure proper nursing actions for treatment.


Thoroughly orient patient to the environment. Place call light within reach and show patient how to call for assistance, answer call light promptly-


Decreases patient’s anxiety level, decreases risk for falls and injury.


Encourage family to participate in care of patient. Discuss with family members home safety plan and patient / family support measures in regards to home environment-


Involves family in education of disease process, safety issues and discharge plans.

Possible Treatments / Tests

Oxygen


Supplemental when cardiac output is decreased


Intravenous RX to slow rapid ventricular response


Calcium Channel Blockers / Beta Blockers/ Anti-arrhythmics


Rate and Rhythm Control


Continuous Cardiac Monitor


Evaluates rate and rhythm


Trans Esophageal Echocardiogram


evaluates for thrombus


Complete Blood Count


checks for anemia / infection


Complete Metabolic Panel


evaluates electrolyte imbalances and renal health status


Thyroid Function Studies


Thyrotoxicosis may precipitate Atrial Fibrillation


Cardiac Enzymes


to evaluate possible MI event


Digoxin Level


to evaluate for sub therapeutic or toxic levels


Chest X-ray


Evaluate possible CHF and lung or vascular pathologies


Cardioversion if rate / rhythm can not be controlled


with intravenous Rx


(contraindicated with atrial clots)


Required if patient hemo-dynamically unstable


Anti-coagulant – Heparin, Lovenox, Coumadin


Atrial Fibrillation puts patient at high risk of emboli


Atrial Fibrillation lasting more than 48 hours requires


Anti-coagulant therapy due to the chance of thrombus formation within the chambers of the heart


Cardiology Consult


Specialized care for patients specific needs


Physical / Occupational Therapy


Evaluates patients functional abilities and plans for implementation and assistance in physical therapies and activities of daily living.