use the nursing process to help you problem solve (care plan) this. step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology of stemis, chf and pulmonary edema - what signs and symptoms of chf and pulmonary edema does the patient have?
step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - i have oragnized the abnormal data that you posted and grouped them into the problems they are a part of. did you look up congestive heart failure? did you look up what a bnp was and what such a high result meant? with the low o2 was there any evidence of hypoxia? to have a psychosocial diagnosis there must be evidence of a psychosocial symptoms to support one. the most commonly used with heart and respiratory patients is anxiety because of their breathing problems (the sob they have). see a nursing diagnosis book for the symptoms of this diagnosis.
- had a stemi a month ago
- pulmonary edema
- history of smoking and drinking
- medical treaments
- balloon pump and stenting
- intubated - what specific monitoring and complications are associated with mechanical ventilation
- tube feeding through an og tube - what specific monitoring and complications are associated with tube feedings
step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use
- rhonchi and rales
- cough with sputum
- abgs were ph-7.55, pco2-35, hco3-30.8 - this is metabolic alkalosis
- 2+ pitting edema in his lower extremities and generalized edema
- ejection fraction is 25%
- troponins positive
- bnp (b-type natriuretic peptide) was 3035
- ekg shows a 1st degree av block
- abdomen was slightly distended
- decreased appetite
- complained of decreased energy
- him and his family didn't realize that water was a fluid
- impaired gas exchange r/t ventilation perfusion imbalance aeb abnormal abgs with ph of 7.55, pco2 of 35, hco3 of 30.8, and po2 of 58.7.
- ineffective airway clearance r/t intubation, retained secretions and smoking aeb rhonchi and rales and a cough with sputum
- decreased cardiac output r/t altered stroke volume and altered electrical conduction aeb 2+ pitting edema in his lower extremities and generalized edema, ejection fraction is 25%, positive troponins, bnp (b-type natriuretic peptide) of 3035, and 1st degree av block on ekg tracings.
- excess fluid volume r/t impaired hydrostatic/oncotic interstitial fluid pressures aeb generalized body edema and bnp (b-type natriuretic peptide) of 3035.
- hyperthermia r/t increased metabolic rate aeb fever
- fatigue r/t stressful situation aeb patient's complaint of decreased energy
- deficient knowledge, fluid restriction r/t information misinterpretation aeb verbalized information from patient that he misunderstood previous discharge instructions regarding fluids allowances.
there is no assessment that provides diagnoses to care for the feeding tube. decreased cardiac output r/t impaired cardiac function aeb 2+ lower extremity edema, generalized edema, and an ejection fraction of 25%.
by using decreased cardiac output we know that "impaired cardiac function" is the problem and that is just restating the problem and not telling us what the cause of the problems are.excess fluid volume r/t impaired excretion of sodium and water aeb edema, pulmonary edema and rales.
the cause of the fluid retention is the failure of the heart. the reason the fluids are collecting in the tissues is because the oncotic pressures of the tissues are greater than the hydrostatic pressure in the vessels so the water is pulled and kept in the tissues. this is a chemical principle. "pulmonary edema" is a medical diagnosis and cannot be used as evidence of this diagnosis. "rales" in the lungs are evidence of a respiratory and breathing problem and not a fluid retention problem.ineffective health maintenance r/t deficient knowledge regarding self-care and treatment aeb (i still have to find a way to phrase this. but him and his family didn't realize that water was a fluid and that's one of the reasons why he was fluid overloaded when he came into er)
i understand what you want to get at. ineffective health maintenance is used when the patient knows they are supposed to do something but don't do it. in this case, the patient didn't know or didn't understand that they were supposed to restrict their fluid intake so it is a knowledge deficit.impaired gas exchange r/t inadequate cardiac function secondary to heart failure aeb rales and pulmonary edema.
gas exchange can only be impaired because something is preventing oxygen and carbon dioxide from being exchanged in the alveoli (the air cells of the lungs where carbon dioxide and oxygen exchange takes place). it has nothing to do with cardiac function. when impaired, the alveoli are blocked by exudates or altered by disease processes (as in copd). again, you can't use a medical diagnosis (pulmonary edema) as evidence that this problem exists. rales are not appropriate evidence that this problem exists either. when carbon dioxide and oxygen are not being exchanged efficiently in the alveoli the patient will have abnormal abgs, become cyanotic, get diaphoretic and show symptoms of hypoxia or hypercapnia.