Is my pt in heart failure??

allnurses Guide · Aug 17, 2014

He likely has chronic dysfunction with that cardiac history; he may have acute on chronic dysfunction in this case but remember these are medical diagnoses.

Are you writing a care plan? I am not an expert in nursing dx, but focus your care plan of what you assessed and the nursing interventions rather than trying to lump them all into a single diagnosis.

**NICU Guy, BSN, RN** · Aug 18, 2014

If you are writing a care plan, it doesn't matter if he has heart failure or not. You are not trying to medically diagnose the patient. Look at your assessment and create your nursing diagnosis according to your assessment. What nursing diagnosis can you use for your observation of his legs and lungs?

ChristineN, BSN, RN · Aug 18, 2014

Whether he is or isn't in heart failure your nursing interventions will be the same. Remember it is not your job to be medically diagnosing. Think about what symptoms brought the pt into the hospital this time, and what issues are currently being addressed. This will help point you toward the priority nursing diagnosis

aimes.k559 · Aug 18, 2014

I am writing a care plan, prioritizing 3 nursing diagnoses and I also have to describe the pathophysiology of a medical condition that has been confirmed and describe the signs and symptoms of this medical condition that the pt is exhibiting

aimes.k559 · Aug 18, 2014

He has pitting oedema, SOB, cool, bluish peripheral extremities. He has a history of IHD, hypertension (though this is medicated) and PAF. Should I go with ischemic heart disease? As I guess that's chronic? And PAF comes and goes, don't think that is causing his chronic SOB

StudentOfHealing · Aug 18, 2014

Patient has had a CABG, I imagine (the blockage that caused the need for a CABG) is related to his Ischemic Heart Disease. The Ischemic heart disease can definitely increase workload of the heart. He has hypertension and if it's not controlled that can also put strain on the left ventricle as it has to overcome a greater afterload or Systemic Vascular Resistance He has atrial fibrillation which places him at risk for a stroke and also RVR which stands for rapid ventricular response... again increasing that workload. I'm sure his poor heart has some degree of failure but as stated before that's a medical diagnosis and that's for an MD/NP/PA to determine. However awesome on pondering. Nothing wrong with wondering what could be the medical Dx.

As far as nursing related. You need a good thorough assessment. Already off the bat I can think of so many diagnoses based on the little assessment you presented.

He's SOB? How does this affect him? ADL's?

What about the cold/bluish feet. Did you assess whether he has intermittent or constant pain? Did you assess how good his sensation is?

Is he on a beta blocker or Ca+ blocker?

Did they give him new meds at the ER? Maybe an ACE inhibitor? You know that can cause a cough.

Is he voiding okay?

There's so much to look for. Assess assess assess.

How is he eating with the SOB?

I can go on forever.

mrsboots87 · Aug 18, 2014

Think symptoms, not disease process. Yes, the disease process of your patient is important, but your job is to treat symptoms and plan ahead. Do you have a nursing diagnoses book, like the NANDA whatever edition its on now? For your careplans, there is a specific structure and specific wording to use for your nursing diagnoses and interventions. The diagnoses should be something along the lines of "(nursing NANDA nursing diagnoses) r/t (cause of nursing diagnoses as listed in the etiology section of the NANDA diagnoses) AEB (insert signs and symptoms from your assessment or from patients chart, can be more than one thing)", and if your r/t factor can also be related to a medical diagnoses then you can add a "secondary to (medical diagnoses)". I only explain this because you were asking if the diagnoses you should go with would be ischemic heart failure. That is a medical diagnoses, not a nursing diagnoses. Also, the cause of his SOB is not for you to diagnose. You TREAT the symptoms, not diagnoses the disease.

To set you in the right direction, would you say that your patient has poor peripheral perfusion (there is a "NANDA" for that)? For symptoms, you found the pitting edema and cool pale skin of the lower extremities, but how were the patient's peripheral pulses?

Also, you mentioned the patient was SOB. Did you listen to lug sounds? Also he has an inhaler for a wheeze, did you hear a wheeze, or maybe something else. There are nursing diagnoses for lung sounds too.

That should help you a little and get you moving in the right direction. I was just in your shoes last semester. The first few clinical shifts and care plans are rough. I can say, get used to all the medical diagnoses for your patient's (i'm assuming you're in LTC for clinical right now). Almost all of them will have heart condition, the majority will have HTN, you'll see a lot of CAD and A-fib, and from looking at charts, you will think your patient is going to die before your shift because everything under the sun is in there. Take a deep breath. Yes, your patient is going to pass in a relatively short time, but you will likely not be assigned patient's that are circling the drain because you are expected to provide most of their care for your shift. It's good that you care about your patients well being, but don't get so worked up about if they are in heart failure or not after your shift. They likely are in at least the beginning to middle stages of a disease that they will die from. Just assess and treat their symptoms and that's all you can do.

LadyFree28, BSN, LPN, RN · Aug 18, 2014

Think symptoms, not disease process. Yes, the disease process of your patient is important, but your job is to treat symptoms and plan ahead. Do you have a nursing diagnoses book, like the NANDA whatever edition its on now? For your careplans, there is a specific structure and specific wording to use for your nursing diagnoses and interventions. The diagnoses should be something along the lines of "(nursing NANDA nursing diagnoses) r/t (cause of nursing diagnoses as listed in the etiology section of the NANDA diagnoses) AEB (insert signs and symptoms from your assessment or from patients chart, can be more than one thing)", and if your r/t factor can also be related to a medical diagnoses then you can add a "secondary to (medical diagnoses)". I only explain this because you were asking if the diagnoses you should go with would be ischemic heart failure. That is a medical diagnoses, not a nursing diagnoses. Also, the cause of his SOB is not for you to diagnose. You TREAT the symptoms, not diagnoses the disease.
To set you in the right direction, would you say that your patient has poor peripheral perfusion (there is a "NANDA" for that)? For symptoms, you found the pitting edema and cool pale skin of the lower extremities, but how were the patient's peripheral pulses?
Also, you mentioned the patient was SOB. Did you listen to lug sounds? Also he has an inhaler for a wheeze, did you hear a wheeze, or maybe something else. There are nursing diagnoses for lung sounds too.
That should help you a little and get you moving in the right direction. I was just in your shoes last semester. The first few clinical shifts and care plans are rough. I can say, get used to all the medical diagnoses for your patient's (i'm assuming you're in LTC for clinical right now). Almost all of them will have heart condition, the majority will have HTN, you'll see a lot of CAD and A-fib, and from looking at charts, you will think your patient is going to die before your shift because everything under the sun is in there. Take a deep breath. Yes, your patient is going to pass in a relatively short time, but you will likely not be assigned patient's that are circling the drain because you are expected to provide most of their care for your shift. It's good that you care about your patients well being, but don't get so worked up about if they are in heart failure or not after your shift. They likely are in at least the beginning to middle stages of a disease that they will die from. Just assess and treat their symptoms and that's all you can do.

This.

If you had not access to the chart, what would you do? Rely on your assessment; then think about how you would intervene, nursing wise.

aimes.k559 · Aug 18, 2014

He has had a stroke which is why he is in the rest home now. I'm guessing it was possibly the atrial fibrillation that caused that? Anyway he has L) sided hemiparesis. He is allergic to ACE inhibitors but takes a B-blocker and a anti-arrhythmic. He has good fluid and food intake. Good sensation on right side, no pain apart from pain in his left hip he says is from sitting in wheelchair for long periods. His SOB doesn't bother him much it's like he's used to it, but he says it can get really bad, he gets a wheeze and he has an inhaler for that. My 3 nursing Dxs were going to be L) hip pain r/t extended periods in wheelchair, Dyspnea r/t decreased cardiac output and insuffient peripheral circulation r/t decreased cardiac output as evidenced by edema

aimes.k559 · Aug 18, 2014

Also I did auscultate his lung fields when I first met him because his SOB was probably the first thing I noticed, they were nice and clear though, and his notes backed this up when I read them later. Are the 3 nursing Dxs I have come up with ok?

allnurses Guide · Aug 18, 2014

How were his posterior tib and Dorsalis pulses? What was his current heart rhythm. What does sitting for extended periods in a wheel chair do for his lower extremity edema?