Patient with acute systolic heart failure

[jbedwards]

I'm working on my caremap for my patient last week. He is an 81 y/o black male admitted for acute systolic heart failure and urinary obstruction after being seen in the office for acute swelling in his legs, ankles, & member.

(He has no known allergies, is MRSA positive. On contact precautions. Past medical history: cardiomyopathy with pacemaker induced with systolic heart failure, HTN, & hyperlipidemia. Ascending aortic aneurysm, 2:1 AV block with pacemaker implanted. Aortic aneurysm repaired with ascending aortic graft. Aortic valve replacement (prosthetic).)

Ok, my gut is telling me (& I could be wrong, I am only a third semester nursing student) that the #1 nursing diagnosis would be decreased cardiac output. Would that apply, however, considering that he is 100% paced? I am stressing over this BAD because I have the most awful clinical instructor on the face of the earth. *sigh*...#just another hurdle to get over.

If I can get over the hurdle of this primary nursing diagnosis for him, I know that I will be fine from there.

Thank you!!

[Esme12, ASN, BSN, RN]

the vitals were: t 97.7f, p72, r18, bp114/69, and o2 sats 96% (room air). MRSA was in the nares, he was on the mupirocin x 5d, then retest (I saw him within the time frame). I have no idea what the blockage was from. he was actually npo when I had him because he was waiting to go down for a cystoscopy, but there was also a possible bladder biopsy, bilateral retrograde, poss transurethreal resec of prostate &/or bilateral tumor. Again, these were all possibilities. He had just come in the night before. the 'cardiomyopathy with pacemaker induced with chronic systolic heart failure was copied directly from his chart. When I asked my instructor about it, she just brushed me off. I am so lost!

Meds: Coreg (hx of htn), Lovenox (he had a prosthetic aortic valve replacement), zetia (hx of hyperlipidemia), furosemide IV, Zestril (htn), multivitamin, bactroban (in nares for mrsa), & demadex (oral mon, wed, fri). he had a hep lock in his left hand with a 22g needle (no fluids running).

When I did my assessment, I noted edema (2-3+) as noted above, but I forgot to mention that he also had a cough that was kind of a dry, non-productive cough (s/e of lisinopril?), & cool dry skin. I also emptied 1475 mL of red-pink urine from his Foley bag at 0845. Beyond that, it was basically normal

I use ackley and gulanek.....they also have a care plan constructor that can be helpful.

So this patient is on 2 diuretics, a blood thinner going to a surgical procedure with heart failure. Could the cough be due to CHF and NOT the ACE inhibitor? What are your concerns with diuretics and patients being diuresed?

I still do not know what this is....

cardiomyopathy with pacemaker induced with chronic systolic heart failure

Does this patient have worsening heart failure due to the pacemaker? What kind of pacemaker was it? Were there two spikes or only one?

This patient is going for a surgical procedure....with a possible cancer diagnosis how would you care for this patient?

So what would you assess for as the nurse caring for this patient? What would you look for first? What can hurt/kill him first?

[Esme12, ASN, BSN, RN]

Risk for Bleeding

Decreased Cardiac Output

Risk for decreased Cardiac tissue perfusion

Ineffective Breathing Pattern

Impaired Comfort

Risk for Electrolyte Imbalance

Fear

Deficient Fluid Volume

Excess Fluid Volume

Risk for Infection

Deficient Knowledge (specify)

Acute Pain

Impaired Urinary Elimination

Urinary Retention

These are what I see may apply to you patient......what evidence do you have to prove that these apply to your patient and why.

[jbedwards]

I use ackley and gulanek.....they also have a care plan constructor that can be helpful.

Do you have an ISBN # for this, or is online?

[jbedwards]

All right, my 4 diagnosis that I chose were decreased cardiac output r/t changes in myocardial contractility; fluid volume, excess; activity intolerance r/t generalized weakness, & urinary retention r/t blockage (in order of importance). Opinions?

[MendedHeart]

All right my 4 diagnosis that I chose were decreased cardiac output r/t changes in myocardial contractility; fluid volume, excess; activity intolerance r/t generalized weakness, & urinary retention r/t blockage (in order of importance). Opinions?[/quote']

The first one is good..I would change yor related to to something like decreased cardiac output r/t weakened heart muscle secondary to CHF/cardiomyopathy AEB lower extremity edema(pitting?), non productive dry cough, fatigue, ef of ?%, BNP of ? IV Lasix schedule etc....

The second and third are fine as long as you can add details and data to back them up such as the example above.

I dont know about tbe fourth. If the pt has a foley, would the obstruction/retention be a priority problem at this time.

How are this pts lung sounds?

Is his cough disturbing his breathing pattern?

[Esme12, ASN, BSN, RN]

Do you have an ISBN # for this, or is online?

I do but you need to purchase the book to get the number to use the online resource. It is a violation of copyright laws to share this information without purchase.

https://evolve.elsevier.com/cs/product/9780323071512?role=student

• ISBN: 9780323071512
  
• Copyright: 2010
  
• Imprint: Mosby
  

[nurseprnRN, BSN, RN]

Sure, you have to know about the medical diagnosis and its implications for care, because you, the nurse, are legally obligated to implement some parts of the medical plan of care. Not all, of course-- you aren't responsible for lab, radiology, PT, dietary, or a host of other things.

You are responsible for some of those components of the medical plan of care but that is not all you are responsible for. You are responsible for looking at your patient as a person who requires nursing expertise, expertise in nursing care, a wholly different scientific field with a wholly separate body of knowledge about assessment and diagnosis and treatment in it. That's where nursing assessment and subsequent diagnosis and treatment plan comes in.

This is one of the hardest things for students to learn-- how to think like a nurse, and not like a physician appendage. Some people never do move beyond including things like "assess/monitor give meds and IVs as ordered," and they completely miss the point of nursing its own self. I know it's hard to wrap your head around when so much of what we have to know overlaps the medical diagnostic process and the medical treatment plan, and that's why nursing is so critically important to patients.

You wouldn't think much of a doc who came into the exam room on your first visit ever and announced, "You've got leukemia. We'll start you on chemo. Now, let's draw some blood." Facts first, diagnosis second, plan of care next. This works for medical assessment and diagnosis and plan of care, and for nursing assessment, diagnosis, and plan of care. Don't say, "This is the patient's medical diagnosis and I need a nursing diagnosis," it doesn't work like that.

There is no magic list of medical diagnoses from which you can derive nursing diagnoses. There is no one from column A, one from column B list out there. Nursing diagnosis does NOT result from medical diagnosis, period, although in many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."

This is one of the most difficult concepts for some nursing students to incorporate into their understanding of what nursing is, which is why I strive to think of multiple ways to say it. Yes, nursing is legally obligated to implement some aspects of the medical plan of care. (Other disciplines may implement other parts, like radiology, or therapy, or ...) That is not to say that everything nursing assesses, is, and does is part of the medical plan of care. It is not. That's where nursing dx comes in.

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.)

To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic" and related factor. Defining characteristics and related factors for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!

If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don't care if your faculty forgot to put it on the reading list. Get it now. When you get it out of the box, first put little sticky tabs on the sections:

1, health promotion (teaching, immunization....)

2, nutrition (ingestion, metabolism, hydration....)

3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)

4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)

5, perception and cognition (attention, orientation, cognition, communication...)

6, self-perception (hopelessness, loneliness, self-esteem, body image...)

7, role (family relationships, parenting, social interaction...)

8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)

9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)

10, life principles (hope, spiritual, decisional conflict, nonadherence...)

11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)

12, comfort (physical, environmental, social...)

13, growth and development (disproportionate, delayed...)

Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.