Care plan help!

Chrystal Marie · Apr 6, 2014

Also I forgot to add that upon admission her BP was 212/110

Summer Days · Apr 6, 2014

Your best resource would be a NANDA book, buy one if you do not have it (you must cite your sources). I have not come across a site that is credit worthy to be cited but here is something to guide you:

Nursing Care Plan

Esme12, ASN, BSN, RN · Apr 6, 2014

We are happy to help ....What semester are you? What care plan resource do you have?

Care plans are all about the patient assessment.

Here is my standard speech.....

Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first.

Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics. From a very wise an contributor daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE from our Daytonite

Assessment
(collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
Determination of the patient's problem(s)/nursing diagnosis
(make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
Planning
(write measurable goals/outcomes and nursing interventions)
Implementation
(initiate the care plan)
Evaluation
(determine if goals/outcomes have been met)

Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

What I would suggest you do is to work the nursing process from step #1.

Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at). The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you.

What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient.

Did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

Another member GrnTea say this best......

A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(nursing diagnosis)_____ . I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics) ________________. He has this because he has ___(related factor(s))__."

"Related to" means "caused by," not something else.

Esme12, ASN, BSN, RN · Apr 6, 2014

No lets look at what information you provided....

Patient is a 95 yo female admitted with possible acute coronary syndrome; chest pain
(Patient presented to the ER after an episode of altered mental status. The staff at the assisted living facility where she resides stated the patient did not recognize where she was or staff members. After admission to the ER, the patient had a bowel movement followed up by "stabbing" chest pain radiating to her entire upper back/shoulder area)
Vitals: T-98.4, P- 84, R- 14, BP- 148/70, Spo2%= 94% on room air
History: CAD, anemia, HTN, heart attack, cardiac shunt (to name a few)
Labs: RBC's- 3.48, Hgb- 10.7, Hct- 32.0, MCHC- 33.3
Assessment data: murmur (which was confirmed by cardiologist as an aortic stenosis murmur), monitor reading shows a prolonged PR interval of 0.24 (which I know is indicative of first degree AV block), absent pedal pulse on L foot, R foot 2+, no other issues with any other pulses- did a Doppler on L foot and still had no luck finding a pulse (neither did my instructor)... but extremities were warm and dry... pt did not complain of sob and was not having any current chest pain.
For this care plan we have to have a primary and a secondary diagnosis. For my primary I would like to do decreased cardiac output but am having some difficultly with the "related to" section because I am not 100% understanding of some of these disease processes. For secondary I would like to do risk for falls. I chose this d/t her age, also she gets around strictly by wheelchair, has a hx of arthritis, osteoporosis, joint limitations, gait disturbance, and has had a L knee replacement, R hip replacement and L femur repair.

Cardiac shunt? What do you mean by that? Is it right to left ot left to right? Atrial or ventricular?

Then..... What is aortic stenosis? Aortic Valve Disease

Why would a patient with aortic stenosis have chest pain after the valsalva maneuver?

Why wold this particular patient have an elevated B/P after an "episode" and why is it important to NOT lower their blood pressure too much nor too quickly.

decreased cardiac output

NANDA describes decreased cardiac output as.....Inadequate volume of blood pumped by the heart per minute to meet metabolic demands of the body

Defining Characteristics: Things your patient has or displayed in your assessment

Altered Heart Rate/Rhythm

Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia

Altered Preload

Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain

Altered Afterload

Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings

Altered Contractility

Crackles; cough; decreased ejection fraction; decreased left ventricular stroke work index (LVSWI); decreased stroke volume index (SVI); decreased cardiac index; decreased cardiac output; orthopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds

Behavioral/Emotional

Anxiety; restlessness

Related Factors (r/t) :

Altered heart rate; altered heart rhythm; altered stroke volume: altered preload, altered afterload, altered contractility

What in your assessment showed you that your patient has these issues/problems.

As far as her being a fall risk....I would say that you have another priority That you should think about mentioned in your assessment.

absent pedal pulse on L foot, R foot 2+, no other issues with any other pulses- did a Doppler on L foot and still had no luck finding a pulse (neither did my instructor)... but extremities were warm and dry

What nursing diagnosis addresses this problem?

Chrystal Marie · Apr 7, 2014

Thanks so much for the response Esme12! I am what you would consider a "junior" nursing student. I attend a community college in an advanced ADN program. (The light is at the end of the tunnel!)

Unfortunately, it did not say whether it was a right to left, or left to right shunt in her history. Aortic stenosis from what I was taught in my pediatrics class is a narrowing at, above, or below the aortic valve. With this there is not enough blood being pumped into the body. That being said, after the patient had a bowel movement I would imagine that there was an increase in the cardiac workload which caused her BP to elevate so quickly? I know that usually, stimulation during the valsavar maneuver will decrease blood pressure, so I geared more towards thinking that if the patient was in some type of acute coronary syndrome that there was a possibility of some myocardial ischemia present. (Again, I am still learning, so forgive me if that just sounds ridiculous).

As far as the other diagnosis at hand with the absent pulse in the patient's left foot, I was leaning towards ineffective peripheral tissue perfusion? The reason I did not choose this right away vs. her risk for falls was that my fundamentals instructor said that if we didn't have at least 3 defining characteristics present for the diagnosis we were choosing that it probably wasn't the right diagnosis. Is this wrong? Trying to follow the order of priority, I understand that her circulation is the biggest issue for me to address. In our care plans, we address short-term goals (as in, what would we do for our patient within an 8-12 hour shift?) When I think about the things I need to address for this patient on my shift, I think, keeping stats WNL and measuring BP and O2 sats frequently (q2hrs, q4hrs, etc).... things of that nature. Then amongst that, her safety. But I totally agree that her "pulseless" left foot is a concern.

Thanks for the advice! I am tearing my brain apart trying to understand the preload/afterload/contractility issues at hand!

nurseprnRN, BSN, RN · Apr 7, 2014

I am tearing my brain apart trying to understand the preload/afterload/contractility issues at hand!

It's helpful if you can step back first and think of what the anatomy of the circulatory system is supposed to accomplish. It's supposed to move a fluid around in a bunch of blood vessels, pumped out at high pressure from the left side of the heart, returned to the heart by passive squeezing in the veins and kept from sloshing backwards by valves in the vessels. Then the right side of the heart is supposed to push it through the lungs (at a lower pressure, because it only has to perfuse the lungs right next door, not all the way down to the toes like the arterial system) to do the gas-exchange thing. Then the fluid goes back to the left side of the heart and out to the body again.

Ventricular filling pressure is just the pressure that is in the ventricles at the end of diastole (LVEDP, left ventricular end-diastolic presssure). For a given volume delivered to a ventricle, pressure can be lower if the ventricle is nice and soft and flexible and empty, ready to accept a new load, than if it's hard and scarred up or has leftover blood in it from the last systole because the AV is hard to open OR because its contractility was so lousy that it didn't empty well. Another term that is used could be "preload," pre- meaning "before systole," and load, well, being the load of blood delivered to the ventricle that it is gonna have to move out in systole. You can measure load as weight or volume, but the way we look at it is by measuring the pressure that occurs there. Pressure changes tell us what's going on in there. Think about a soft balloon (low pressure) and a hard one (high pressure). Which has more air in it?

Let's look at the blood flow in a linear fashion. I regret that I cannot give these in color so you can see the blue of venous, the red of arterial. But hey. Draw them on a piece of paper in color. The lungs are pink :)

Body > Veins > Vena Cava > Right Atrium > tricuspid valve > Right Ventricle > pulmonic valve > Pulmonary Artery > LUNGS >Pulmonary Vein > Left Atrium > mitral valve > Left ventricle > aortic valve > Arteries > Body

Think about when the valves between two chambers are OPEN. By definition, each chamber must be at the same pressure, right? So, at the end of diastole, just before systole, the pressure in the LV is the same as LA pressure is the same as the pressure in the pulmonary vein (no valve in the way there) and in the pulmonary capillary bed. And since there are no valves in the pulmonary capillary bed, tracking backwards, you can see that LV end diastolic pressure equals end-diastolic PULMONARY ARTERY PRESSURE, which is, conveniently, what we look at when we are wondering what's going on in the left heart. You can even follow it back all the way to the right atrium, and the vena cava-- central venous pressure! Wow!

OK. Now, why do we care about LV end-diastolic (filling) pressure? It's because that's where the work of supplying the whole body goes. For that, I wish I could draw you a nice little curve here. I can't, so I will describe it and YOU will draw it on a piece of paper to look at while we chat.

Horizontal axis: label this "preload" or any other term you like. Filling pressure, PA diastolic pressure is the same thing (see above) and you can even extrapolate all the way back to central venous pressure, for a rough trend-setting bit of data.

The vertical axis you will call "cardiac output," or "blood pressure," because the line we are going to draw is going to explain something really cool.

Start lowish on the left, near the vertical axis-- low filling pressure means low BP. Think: hemorrhage, hypovolemia, makes your BP low, right?

Slant the line upwards to the right, showing that blood pressure (cardiac output) increases the more blood you put into the heart. (Tank up that hypovolemic guy, and BP improves.) But at some point, that upward-going curve peaks, flattens out...and then it DROPS as the preload keeps increasing. This is because cardiac muscle is like a rubber band-- the more you stretch it, the harder it contracts...to a point, at which point it gets too stretched out and actually contracts less well. Draw a little asterisk at the top of that curve, where it starts to fall, then let it fall a little bit. That asterisk marks the best cardiac output you can get-- preload and output are optimal for that heart. Beyond that point, where the line slopes downwards, lies congestive heart failure- the heart is too full, has more than it can handle, and it fails. (This is, BTW, called the Frank-Starling Law of the heart, and you just drew the Frank-Starling curve) Pressure backs up into the pulmonary capillary bed making the lungs get wet and heavy. This is when people get diuretics (to decrease that excessive preload) AND drugs to improve their contractility.

Of course, if contractility is lousy because of coronary artery disease, previous MI, or whatever, this whole curvy line thing will kinda slide over to the left-- the myocardium will fail with lower pressures than it would if it had better contractility. Better contractility (a right shift) means it will handle more preload (higher filling pressures) and make better BP out of it. Draw a second curve to the right of the first one, parallel to it, to see that. With me so far?

I think you can see how CAD will give you higher filling pressures-- when the heart is failing a bit, it goes past the top of its curve more easily because its contractility is diminished.

Mitral STENOSIS will, in fact, decrease your LV preload, but it will increase pressures back into the lungs and, eventually, the right heart, because of the resistance to flow from the right side to the LV. Mitral REGURGITATION, on the other hand, will result in higher filling pressures because when the ventricle contracts in systole, some of the blood goes backwards, leaving excess sloshing around between the atrium and ventricle; the ventricle will have to accept a higher reload at diastole, and it doesn't like it. Over the top of the curve again.

Another concept is that inhaling makes a negative pressure (suction) in the thorax, right? That's how the air gets in. But this also makes for increases in venous return. As a matter of fact, you can sometimes see the arterial pressure fluctuate wth respiration because of the change in preload related to that increased inflow of blood during inhalation and a decreased inflow of blood during exhalation (high chest pressures, right?). So now think what happens to this lady when she does a Valsalva. The resistance to blood flow out of the ventricle is higher (so how does that old ventricle and that hinky aortic valve like that?) AND there's less venous inflw (and how does that old ventricle and hinky valve do with that?).

Well, I hope this hasn't confused you. I used to tell my students they had to know this because we saw lots of people with all sorts of deficits, but if they didn't have hearts and lungs, they were dead and we didn't have to take care of them anymore. Works in every possible area you could work, except pathology. Please ask me if I've confused you anywhere.

Esme12, ASN, BSN, RN · Apr 7, 2014

Thanks for the advice! I am tearing my brain apart trying to understand the preload/afterload/contractility issues at hand!

It is probably a left to right because of the higher pressures in the left side of the heart being so high.....it shunts the blood to the right.

The right side of the heart, composed of the right atrium and ventricle, collects and pumps blood to the lungs through the pulmonary arteries. The lungs refresh the blood with a new supply of oxygen, making it turn red.

Oxygen-rich blood, "red blood," then enters the left side of the heart, composed of the left atrium and ventricle, and is pumped through the aorta to the body to supply tissues with oxygen.

Four valves within your heart keep your blood moving the right way. The tricuspid, mitral, pulmonary and aortic valves work like gates on a fence. They open only one way and only when pushed on. Each valve opens and closes once per heartbeat — or about once every second.

A beating heart contracts and relaxes. Contraction is called systole, and relaxing is called diastole.

During systole, the ventricles contract, forcing blood into the vessels going to your lungs and body — much like ketchup being forced out of a squeeze bottle. The right ventricle contracts a little bit before the left ventricle does. The ventricles then relax during diastole and are filled with blood coming from the upper chambers, the left atria (contains oxygenated blood from the lungs/luminary vein)and right atria (from the Superior/inferior vena cava). Then the cycle starts over again.

The heart is nourished by blood vessels called coronary arteries extend over the surface of your heart and branch into smaller capillaries. The heart also has electrical wiring, which keeps it beating. Electrical impulses begin high in the right atrium and travel through specialized pathways to the ventricles, delivering the signal to pump. (PQRST) The conduction system keeps the heart beating in a coordinated and normal rhythm, which in turn keeps blood circulating. The continuous exchange of oxygen-rich blood with oxygen-poor blood is what keeps us alive.

http://www.learntheheart.com/EKGreview.html

ECG Learning Center - An introduction to clinical electrocardiography

ECGpedia

images?q=tbn:ANd9GcRksBpnpPIZpT7BuWKSU4O4O9-8qbNhC2E-1UKt_R_lXVBxvR0c

Preload is about volume. If the water pressure is low, the water output will be a trickle, not enough to water and sustain your pretty garden. If the volume is too much, it will back up your plumbing system (Right-sided heart failure engorged liver, systemic edema, etc, or left-sided failure pulmonary edema.)

Afterload is about pressure or resistance. If there is a link or narrowing in your garden hose, the volume will back up AND the output will drop. Think of it like a garden hose.........

A good analogy is that your hose has gone form a garden hose to a fire hose or developed huge leaks and it will either get more blood to the right places easier (decreasing afterload so the heart doesn't have to work as hard and will therefore work better) ...or you will not get the blood to where it need to go until you "patch it up" (constrict the blood vessels to a more normal size like the vasodilation that occurs with sepsis)or stop the bleeding by sealing the leak(the source of hemorrhage)....OR....

Gross analogy, but it works...Think about flushing a toilet......you flush, and then flush again right away......nothing happens right? This is because the tank doesn't have time to fill....PRELOAD is decreased in the tank.

What if the toilet is plugged up? When you flush, it backs up....this is too much afterload.

Preload = Volume

Afterload = Pressure/Resistance

http://cvphysiology.com/Blood Pressure/BP010.htm

Esme12, ASN, BSN, RN · Apr 7, 2014

With a stenotic valve the heart is pumping against a hard closed obstruction. The heart needs to compensate by maintaining a high enough blood pressure to "push" the blood through the calcified valve. With the drop in B/P there isn't enough back pressure to hold the valve open or send oxygenated blood out to the aorta...immediately stopping blood flow to the coronary arteries (they originate off of the aorta) causing sudden intense chest pain.

Think of an old pipe that is clogged up with calcium deposits....the water just trickles out of the faucet never having a good flow....then someone in the house turns on the shower or flushes the toilet....now you have no pressure or water.

Nadroujj · Apr 7, 2014

Patient has a risk for impaired skin integrity dt bed rest, age, previous history, low oxygen, and possible decreased circulation to that left leg. Since you said it was still warm and pink perhaps not.

Chrystal Marie · Apr 11, 2014

Thank you all for your help! I hope I get a good grade on this care plan ")