basically, what you have is a patient with a dysrhythmia and all the symptoms that come with that. i encourage you to take a really good look at the nursing assessment
that you and the hospital nurses
did on this patient. i have to beg your pardon on this, but his assessment could not have been normal. his physical assessment may have been normal, but the physical assessment is only one part of the assessment process. there should be some clues in the history of present illness of the doctor's h&p
and in the review of systems or history to help you out here. there will also be some issues with adl's and safety that you need to address along with the obvious cardiac output situation. how is this arrhythmia going to affect this patient's performance of his adls? for example, when a patient is having svt, do they get dizzy, lose their balance, become at risk for fainting or a fall? insofar as the medication he is receiving, this is a collaborative problem of nursing (depends on doctor's orders in order to perform) and is, therefore, not an independent nursing action. some instructors want these collaborative actions included on care plans
; others do not. make sure you know where your instructors stand on this issue. there are plenty of other independent actions you are going to be able to come up with for this patient anyway (although at this point i know you are not able to think of any). there is always going to be a teaching requirement to get the patient familiar with what this disease process is and the importance of taking medication regularly to keep it under control. there may be some activity restrictions as well.
here is a really nice article from the cleveland clinic foundation (they are world-renowned in cardiac care) that will only take you a few minutes to read and may give you some direction to take with your care plan as well:
- management of arrhythmias
some of the nursing diagnoses that you will want to consider are (this is not an inclusive list):
- decreased cardiac output r/t altered electrical conduction
- activity intolerance r/t decrease cardiac output
- anxiety r/t threat of death or change in heath status
- ineffective tissue perfusion: cerebral r/t interruption of cerebral arterial flow secondary to decreased cardiac output
- ineffective health maintenance r/t deficient knowledge regarding self0care of disease
your aebs that would go along with any of these diagnostic statements would be the symptoms to support the use of those particular nursing diagnoses. if you have a current nursing care plan book, you should be able to find the defining characteristics for each of those diagnostic categories listed for you as a guideline for you to use.
hope these are some ideas that you can work with. look a little farther into this patient's record and you are going to find the data you need to support the nursing diagnoses you choose.