Patient with acute systolic heart failure

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    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, & penis.

    (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!!
    Last edit by Joe V on Sep 16, '13 : Reason: spacing

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  3. 18 Comments...

  4. 0
    A proper nursing dx is written based on your assessment data, not based on a medical make sure you have assessment data to prove that a given nursing dx applies to the pt.

    However, on the medical dx side of things...what is cardiomyopathy (break it down into its roots...cardio- and -myopathy...what do each mean and what does it mean when they are put together)? What are the implications of cardiomyopathy as related to the pumping ability of the heart (and, thus, the cardiac output)? What does a pacemaker do? Does it make the pump stronger? Will it improve the amount of blood the heart pumps with each beat (i.e. improve the stroke volume)?
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    You are falling in that trick bag of looking at the medical diagnosis for your nursing diagnosis. Many students do......

    Let the patient/patient assessment drive your diagnosis. Do not try to fit the patient to the diagnosis you found first. You need to know the pathophysiology of your disease process. You need to assess your patient, collect data then find a diagnosis. Let the patient data drive the diagnosis.

    What is your assessment? What are the vital signs? What is your patient saying?. Is the the patient having pain? Are they having difficulty with ADLS? What teaching do they need? What does the patient need? What is the most important to them now? What is important for them to know in the future. What is YOUR scenario? TELL ME ABOUT YOUR PATIENT...

    The medical diagnosis is the disease itself. It is what the patient has not necessarily what the patient needs. the nursing diagnosis is what are you going to do about it, what are you going to look for, and what do you need to do/look for first. From what you posted I do not have the information necessary to make a nursing diagnosis.

    Care plans when you are in school are teaching you what you need to do to actually look for, what you need to do to intervene and improve for the patient to be well and return to their previous level of life or to make them the best you you can be. It is trying to teach you how to think like a nurse.

    Think of the care plan as a recipe to caring for your patient. your plan of how you are going to care for them. how you are going to care for them. what you want to happen as a result of your caring for them. What would you like to see for them in the future, even if that goal is that you don't want them to become worse, maintain the same, or even to have a peaceful pain free death.

    Every single nursing diagnosis has its own set of symptoms, or defining characteristics. they are listed in the NANDA taxonomy and in many of the current nursing care plan books that are currently on the market that include nursing diagnosis information. You need to have access to these books when you are working on care plans. You need to use the nursing diagnoses that NANDA has defined and given related factors and defining characteristics for. These books have what you need to get this information to help you in writing care plans so you diagnose your patients correctly.

    Don't focus your efforts on the nursing diagnoses when you should be focusing on the assessment and the patients abnormal data that you collected. These will become their symptoms, or what NANDA calls defining characteristics.

    From a very wise an contributor Daytonite.......make sure you follow these steps first and in order and let the patient drive your diagnosis not try to fit the patient to the diagnosis you found first.

    Here are the steps of the nursing process and what you should be doing in each step when you are doing a written care plan: ADPIE

    1. Assessment (collect data from medical record, do a physical assessment of the patient, assess ADLS, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology)
    2. Determination of the patient's problem(s)/nursing diagnosis (make a list of the abnormal assessment data, match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use)
    3. Planning (write measurable goals/outcomes and nursing interventions)
    4. Implementation (initiate the care plan)
    5. Evaluation (determine if goals/outcomes have been met)

    Care plan reality: The foundation of any care plan is the signs, symptoms or responses that patient is having to what is happening to them. What is happening to them could be the medical disease, a physical condition, a failure to perform ADLS (activities of daily living), or a failure to be able to interact appropriately or successfully within their environment. Therefore, one of your primary goals as a problem solver is to collect as much data as you can get your hands on. The more the better. You have to be the detective and always be on the alert and lookout for clues, at all times, and that is Step #1 of the nursing process.

    Assessment is an important skill. It will take you a long time to become proficient in assessing patients. Assessment not only includes doing the traditional head-to-toe exam, but also listening to what patients have to say and questioning them. History can reveal import clues. It takes time and experience to know what questions to ask to elicit good answers (interview skills). Part of this assessment process is knowing the pathophysiology of the medical disease or condition that the patient has. But, there will be times that this won't be known. Just keep in mind that you have to be like a nurse detective always snooping around and looking for those clues.

    A nursing diagnosis standing by itself means nothing. The meat of this care plan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this order for you to pick any nursing diagnoses for a patient you need to know what the patient's symptoms are. Although your patient isn't real you do have information available.

    What I would suggest you do is to work the nursing process from step #1. Take a look at the information you collected on the patient during your physical assessment and review of their medical record. Start making a list of abnormal data which will now become a list of their symptoms. Don't forget to include an assessment of their ability to perform ADLS (because that's what we nurses shine at).

    The ADLS are bathing, dressing, transferring from bed or chair, walking, eating, toilet use, and grooming. and, one more thing you should do is to look up information about symptoms that stand out to you. What is the physiology and what are the signs and symptoms (manifestations) you are likely to see in the patient. did you miss any of the signs and symptoms in the patient? if so, now is the time to add them to your list.

    This is all part of preparing to move onto step #2 of the process which is determining your patient's problem and choosing nursing diagnoses. but, you have to have those signs, symptoms and patient responses to back it all up.

    Care plan reality: What you are calling a nursing diagnosis is actually a shorthand label for the patient problem.. The patient problem is more accurately described in the definition of the nursing diagnosis.

    So tell me about your patient.......What do they need? What do they c/o? What is your assessment......What does this tell me about the patient? This givens me no information about what your patient needs, what brought them to the hospital...what is their complaint?
    Wise Woman RN likes this.
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    It's not that I WANT to look at the medical diagnosis to write up my care plan, it's that my instructor is all but FORCING us to. I am aware that the patient is what needs to lead the care plan, but she does not agree with that. (I wasn't kidding when I stated that she was a nightmare). That is why I am somehow trying to fit this together...
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    as far as assessment data: vitals were within normal range. he did have cool skin and some edema (+2-3) in his lower extremities, but other than that there was really nothing that I could say was 'off'...he is on constant tele monitoring but was in a normal paced rhythm. he had a foley cath that had 1475mL of pink/red sedimentary urine in it that I emptied at 0845. it was supposedly emptied before shift change, but with that amount of urine in it I am not sure, considering that shift change was at 0700. there were no c/o pain...or any c/o anything for that matter...
  8. 0
    Looking at your scenario .....
    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, & penis.
    (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)
    Is this a real patient? What is your assessment of him? What does he complain of? What does he need? What symptoms does he exhibit? What meds is you patient on?

    First, you need to know what acute systolic heart failure is....
    what are the symptoms? Heart Failure

    Urinary obstruction....from what? The prostate? A tumor? A kidney stone? Was this patient urinating at all? Were they in pain?

    What were the patients labs? What were their vital signs? What was your assessment?

    What do you mean by...
    cardiomyopathy with pacemaker induced with systolic heart failure....
    do you mean they have pacemaker induced systolic failure?....... or....... do they have systolic failure with the cardiomyopathy with a pacemaker for 2:1HB.

    Where is the MRSA?

    Tell me about your patient! Then we can start the care plan.
  9. 1
    It makes NO sense to me that you make a care plan at this stage of the game that isn't about the patient's complaints ....that is what care plans are all about. can't change out your instructor. My guess of what she is looking for is....what would YOU as the nurse be looking for in a patient with these diagnoses. What care plan book do you use? Do you have the NANDA I book? get report on this are planning your you go into assess this man....what would you as the nurse want to look for.......

    Next you look at the information you have...your patient have edema.....according to your initial statement
    acute swelling in his legs, ankles, & penis.
    or severe swelling. What was his RR rate his 02 sat? Did you listen to his lungs? Are you sure that the previous shift didn't empty the foley or is his output increased due to diuresis? What time was his lasix given? Did you check the previous shifts documentation? Did you check the MAR/EMAR?

    Why is the urine pink? Is this patient anti-coagulated? What else could be causing his pink urine? Could this have anything to do with his prostate?
    jbedwards likes this.
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    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
  11. 0
    Lasix was last given at 2200 (I went in at 0700). No, I am not sure that the last shift emptied his bag. They put in his EMR that he did, but this is a hospital that is noted for its poor quality of care around here, & I have noted many discrepancies myself in his chart, so I cannot say that they did. That's part of why I am having such a problem. He stated that they did, & I almost believed him until his doctor came in to speak to him & he told her that she was the one that emptied his bag before my shift! Lung sounds were clear & equal bilaterally. Pulse was equal & strong, excepting that they were slightly less palpable in his feet.
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    *btw, thank you for the wording change!!! (acute to severe)...that looks much better!

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