HI! I was hoping someone could help me out with this care plan I have. I have spent hours and trolled the internet for answers to no avail! BTW I am a 2nd semester RN student!
My patient is a young man with an ejection fracture of 28%. He came in through ED with c/o chest pains unrelieved with nitroglycerin and increased troponin and CK with elevated BP 221/87; normal echo in sinus rhythm and the following hx:
Insulin dependent DM (uncontrolled) X 7 yrs CABG X 3 yrs ago with 6 stents
Hypertension X yrs Amputation of left great toe X yrs ago
Hyperlipidemia X yrs Amputation of right third toe X yrs ago
CAD X 3yrs
Ischemic Cardiomyopathy x yrs
Peripheral neuropathy X yrs
Retinopathy X yrs
His v/s BP: 136/80; Pulse: 76 regular 2+/3, Apical pulse: 82 regular, radial pulses 2+/3 regular bilat.; femoral and pedal pulses 1+/3 weak bilaterally; lung sounds dimishined throughout. O2 sat 96% on 2L n/c
He had an AICD placed the day prior to my shift.
My care plan is Decreased cardiac output r/t alterations in preload, afterload and myocardial contractility 2° cardiomyopathy and cardiac ischemia x 4 yrs ago amb (as manifested (evidenced) by) dyspnea on exertion, orthopnea, c/o "dizzy and tired when I walk", ejection fracture of 28%
I have completed my expected outcome for the DOE, orthopnea and weakness; however my program requires us to have an EO for each amb. So for the ejection fracture i am stuck. I have the EO stated as Patient will have an improved ejection fracture within 2 days but now I am thinking this isnt possible. After reading through my books and journals it seems as though an ejection fracture seldom improves and when it does they dont know why?! And now my EO sounds more like a MD problem than a RN one.
I have made some NI for this EO but I am not sure if they are even accurate or good. Here is what I have so far
2a. Assess ejection fracture
2b. Monitor lab results daily
2c. Review results of diagnostic imaging (ECG, EKG, radionuclide) Q shift
2d. Administer Coreg, nitrate, rouvastatin ,Lasix, spironolactone, Norvasc, Lisinopril, Spironolactone as scheduled
2e.Consult with case manager to refer to cardiac rehabilitation program for education, evaluation. And guided support to increase activity
Do you think I am on the right track with using EF as a EO? Or should I change it? If I change it, what else would show decreased cardiac output? His BP is not bad, he has no peripheral pulses but that is more r/t neuropathy I think... His HR is WNL and well controlled on his current medications....thanks in advance
Apr 12, '13
Don't forget about stroke volume either. An increase in strike volume will increase EF.
I feel like I didn't explain myself thoroughly for some reason. Anyway, EF will also affect CO and Map, as they would effect the EF. They all kind of play off of each other. If that makes sense.
By seeing cap refill < or = to 3 seconds you know that the patient is becoming hemodynamically stable.
Is fluid volume (deficit or overload) one of your Dx?
Last edit by PatMac10,RN on Apr 12, '13