Nursing Care Plan for Medical Diagnosis of Syncope

  1. 0
    I am having to do a concept map (care plan) on a fictional patient for a case study in my EKG class. I'm having a hard time picking the right 4 diagnoses for this because there is only a limited amount of data and some of it is conflicting. Theres something im not getting and i need help figuring it out. These are the assessment data:

    81 yo male brought to ED after being found by a friend passed out at home. no bruising or lacerations were sustained during the fall.

    Hx:
    CVA- 1 year ago with residual weakness on rt side, difficulty swallowing, PEG tube with tube feedings
    HTN
    Osteoarthritis

    Meds:
    lasix, colace, ASA, cardizem, coumadin, KCL, Benicar

    Objective data:
    VS: T-98.4, RR-20, P-70, BP 143/90, SaO2 97% 3L NC. LOC-alert X3, unsteady gait, strong carotid pulse, strong peripheral pulse, no edema, no JVD, tele- arrhythmia, no S3 or S4, saline lock rt hand, side rails up, no dressings or drains, voiding clear 800 mL q shift, continuous feeding Jevity, pt depressed wants to go home.

    Labs: RBC 4.1, Hgb, & Hct WNL, platelets 125,000, PT 28 secs, INR 2.5, electrolytes WNL

    I wish there were ABG's. Anyways, according to maslow, physiologic needs are priority. I was thinking Decreased Cardiac Output r/t alteration in rhythm a.e.b. arrhythmias and syncope. However the reason he fainted could be that hes on two antihypertensives at once. I've also got risk for falls (obvious), Ineffective Tissue Perfusion (cerbral), and Knowledge Deficit.

    Can anybody help guide me bit??


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  4. 11 Comments so far...

  5. 0
    He's a definite risk for injury r/t right sided hemiparesis - risk for falls isn';t a nsg diag
    impaired mobility r/t right sided hemiparesis a/e/b a/e/b need for ? assist with ambulation
    risk for aspiration r/t impaired swallowing

    There's a risk for bleeding because the INR is high and platelets low but I don't remember the nsg diag for that.

    HTH.
    You don't know if his cardiac output is decreased - pulse is WNL, BP is high.
  6. 2
    go through the scenario and pull out all the data that they have given you, put it into a list. look up the side effects of the medications the patient is on to see if any of them correspond to any of the data in the scenario. potential side effects of medications can be used to create "risk for" diagnoses. use the data list to make links to defining characteristics of nursing diagnoses. that is what i do. that is how these case scenarios are designed.

    cardiac output r/t alteration in rhythm a.e.b. arrhythmias and syncope
    syncope is a medical diagnosis. what things can cause syncope? what are the consequences? loss of balance and falling? keep in mind that we are not doctors. we are nurses. our job is to help the patient deal with their response to their disease or condition.
    risk for falls (obvious), ineffective tissue perfusion (cerebral), and knowledge deficit
    i would probably diagnose risk for falls based on the patient's age and the fact that the scenario stated that he was found "passed out at home" and that there had been a fall.

    the only evidence of ineffective tissue perfusion (cerebral) is that the patient has diffficulty swallowing, but the cva was one year ago. diagnosing is a step-by-step process that involves assessing the patient first and then analyzing the data that was collected. in this case, assessment was done for you. all you need to do is pick out the abnormal data. abnormal data becomes the foundation of defining characteristics that will support any nursing diagnosis (nursing problems) this patient will have. for example, ineffective tissue perfusion, cerebral r/t interruption of blood flow aeb difficulty swallowing. i would diagnose impaired swallowing r/t neuromuscular impairment secondary to a cva one year ago aeb difficulty swallowing based on the fact that this patient had his cva one year ago and his cerebral tissue perfusion problem was resolved long ago. the swallowing problems are a permanent residual that he has been left with as a result of the cva. if you read about cvas before jumping to picking diagnoses first you would have caught that. one of the biggest mistakes students make is picking diagnoses by just reading their labels. ineffective tissue perfusion, cerebral is a label, a descriptive phrase that stands in place of the true nursing problem which is the definition of this diagnosis: decrease in oxygen resulting in the failure to nourish the tissues at the capillary level (page 228, nanda-i nursing diagnoses: definitions & classification 2007-2008). that gives a whole different meaning to what ineffective tissue perfusion means, doesn't it? here is the definition of impaired swallowing: abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function (page 218, nanda-i nursing diagnoses: definitions & classification 2007-2008). that sounds like the swallowing problem that this patient has.

    correct me if i missed something, but there is absolutely no data in the scenario to support using deficient knowledge. you cannot manufacture data.
    VickyRN and suzy253 like this.
  7. 0
    Ive changed my diagnoses up a lil bit. I have risk for decreased cardiac output and Knowledge deficit as my primary. I stick to my knowledge deficit because that is a important factor in the healing process. under knowledge deficit, i would put r/t emotional state affecting learning (anxiety and depression), which are in the h&p. Its under cardiac care plans (dysrhythmias) in my care plan book. I did refresh my knowledge on CVA's before i started. I took into account that he has PEG tube and had the stroke a year ago and no history of pneumonia. lungs are clear, so impaired swallowing didnt seem priority. I also looked up his drugs, and cardizem which is used to treat his HTN can cause arrhythmias and hes on coumadin. The underlying cause of his stroke could be a blood clot thrown from within his heart due to the arrhythmia. Im trying to look into it that way beacuse this is EKG class. i agree ineffective tissue perfusion does not go with this client.
  8. 2
    this man has a cardiac output problem so risk for decreased cardiac output is a wrong diagnosis. a stroke (cva) is a cardiovascular event. the man's stroke was a year ago and atrial fib is the usual culprit. it does cause dizziness and syncope.

    but now, despite being on two blood pressure medications he still has a b/p of 143/90. he also is on coumadin and has an rbc count of 4.1, which is low, and platelets of 125,000, which are also low, and would suggest to me that there might be some bleeding going on that hasn't been found yet. blood loss anemia also causes dizziness and syncope. add to that that he is also getting lasix. maybe there was some dehydration going on as well, but we can't know since there are no electrolyte results. your scenario does not say that he was admitted this second time with another cva and i think that is important information that wasn't said. it is very possible that he became dizzy because of an anemia secondary to bleeding and/or dehydration which is what led to this fall and him staying passed out until found by his friend. that is clearly decreased cardiac output. either or both would have been due to complications as a result of treatment of his cardiac problems.

    alteration of any of these factors will affect cardiac output:
    • cardiac output
      • heart rate - beats per minute
      • stroke volume - amount of blood pumped per beat (this includes anemia, dehydration)
    please read the related factors for deficient knowledge carefully.
    just because your care plan book says that "r/t emotional state affecting learning (anxiety and depression), which are in the h&p." doesn't mean that's exactly how you should write it. people have a knowledge deficit for cognitive (perception) reasons. they don't understand or don't have access to the learning. their emotional state can interfere with the intake and retaining of information, but if the patient has anxiety then they need to be diagnosed with anxiety. depression is a medical diagnosis and cannot be used in a nursing diagnostic statement. and, you certainly can't indicate in your diagnosis that the information comes via "the h&p". what you should have is a deficient knowledge (specify the topic) r/t learning affected by emotional state aeb [evidence]. include stuff about the patient's anxiety (ex: poor eye contact, statements that they get nervous about learning new things or learning makes them nervous) in your evidence.

    just my . it's your grade.
    VickyRN and suzy253 like this.
  9. 0
    im just asking for a little guidance, not someone throwing things in my face like i dont know anything. you can go belittle someone else because your advice is not welcome to me anymore
  10. 0
    Well, let's see how your instructor likes your ideas. Post back when you get your final grade on this assignment and let us know.
  11. 1
    Serenity,

    I am appauled at your lack of gratitude of Daytonite's help. This person has 32 years of experience. They pointed out to you that you can't even differentiate the difference between a "Risk for" diagnosis and when a patient actually has a problem. Forget getting into any further more complex Dx. You need to figure that one out first.
    I'm in your class and working on the same case study. I don't know who you are, but I hope I never have to work with you. You are the perfect example of all the nasty nurses out there.

    I hear McDonald's is hiring.
    Gruffy
    3GTOBE likes this.
  12. 1
    Quote from serenitychic09
    im just asking for a little guidance, not someone throwing things in my face like i dont know anything. you can go belittle someone else because your advice is not welcome to me anymore
    Are you kidding me? You asked for help and you received it. Daytonite puts a lot of work into helping out students with care plans such as yourself. I am also appalled!!! Unbelievable!!!:angryfire
    CrystalClear75 likes this.
  13. 0
    Quote from serenitychic09
    im just asking for a little guidance, not someone throwing things in my face like i dont know anything. you can go belittle someone else because your advice is not welcome to me anymore
    You really have me boiling. I hope I figure out who you are in my class, so I can dismiss you as the nurse making my careplan and giving me meds in the future.

    You really need to take a step back and reevaluate your attitude and send some apologies. I always think everyone has a bad day and deserves a second chance. I hope you take the opportunity to do so. Good luck to you.


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