question regarding care plan

  1. 0
    Hi people,

    I am stumped on this care plan. My pt woke up c/o chest pain an hour before he arrived to hospital. He was given two NTG by ems prior. He got diagnosed with STEMI and got emergent PCI. Two stents were placed in LAD and an IABP and had a transvenous pacemaker in him and he is on the vent. He had a hx of htn, dm, and high cholesterol. 51 year old.

    We have to pick three dx and prioritize which one are the most important. I picked:


    Nursing Dx #1
    Decreased Cardiac Output r/t myocardial injury secondary to AMI aeb decreased in BP, elevation in HR, dyspnea, dysrhythmias, diminished pulses, pulmonary edema, and elevation in CK-MB and Troponin levels.

    Nursing Dx #2
    Ineffective Tissue Perfusion r/t cardiac ischemia, interrupted blood flow and impaired transport of oxygen aeb 100% occlusion of LAD, decrease in CO, EF <15, tachycardia, dyspnea, chest pain, and weak peripheral pulses

    Nursing Dx #3

    Deficient knowledge r/t family unfamiliarity with procedure of PCI and IABP, with new condition: AMI, treatment, and the complexity of the treatment aeb family anxiety and stress about patient current status, family questioning RN about PCI and IABP regarding how the treatment works and how the treatment helps patient, RN providing written information about the treatment and MI, and RN demonstrates to family members how IABP machine looks like and what each signal/button indicates.


    But I'm confused because would he still have decrease CO considered he already have a balloon pump? Would he still have ineffective perfusion considered he is on the vent? Is deficient knowledge really an important diagnoses consider all that is going with this patient? I am also stumped that he has bloody drainage around his penis but has no sign of infection. No elevated WBC, no fever, nothing. So what can cause bloody drainage? Low level UTI?, prostate problem?, kindney problem? Please help, I'm pulling out my hair!
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  4. 1
    Quote from ctran
    Hi people,

    I am stumped on this care plan. My pt woke up c/o chest pain an hour before he arrived to hospital. He was given two NTG by ems prior. He got diagnosed with STEMI and got emergent PCI. Two stents were placed in LAD and an IABP and had a transvenous pacemaker in him and he is on the vent. He had a hx of htn, dm, and high cholesterol. 51 year old.

    We have to pick three dx and prioritize which one are the most important. I picked:

    Nursing Dx #1
    Decreased Cardiac Output r/t myocardial injury secondary to AMI aeb decreased in BP, elevation in HR, dyspnea, dysrhythmias, diminished pulses, pulmonary edema, and elevation in CK-MB and Troponin levels.

    Nursing Dx #2
    Ineffective Tissue Perfusion r/t cardiac ischemia, interrupted blood flow and impaired transport of oxygen aeb 100% occlusion of LAD, decrease in CO, EF <15, tachycardia, dyspnea, chest pain, and weak peripheral pulses

    Nursing Dx #3
    Deficient knowledge r/t family unfamiliarity with procedure of PCI and IABP, with new condition: AMI, treatment, and the complexity of the treatment aeb family anxiety and stress about patient current status, family questioning RN about PCI and IABP regarding how the treatment works and how the treatment helps patient, RN providing written information about the treatment and MI, and RN demonstrates to family members how IABP machine looks like and what each signal/button indicates.

    But I'm confused because would he still have decrease CO considered he already have a balloon pump? Would he still have ineffective perfusion considered he is on the vent? Is deficient knowledge really an important diagnoses consider all that is going with this patient? I am also stumped that he has bloody drainage around his penis but has no sign of infection. No elevated WBC, no fever, nothing. So what can cause bloody drainage? Low level UTI?, prostate problem?, kindney problem? Please help, I'm pulling out my hair!
    I know I have told you before.....the care plan is all about the patient assessment of the patient and how it applies to the patients diagnosis. Are these diagnosis that we provided to you or you gave your patient based on the assessment.http://allnurses.com/nursing-student...ml#post6364564

    What is this patients underlying diagnosis?

    They came to the ED with a complaint of CP got rushed to the Cath Lab. The patient suffered a massive MI AEB ejection fraction is less than 15% the patient is intubated and on a ventilator and has gone through an invasive intervention.

    When a heart attack is bad enough the heart goes into shock..... what is cardiogenic shock? what is the treatment for cardiogenic shock? What is an IABP...what does it do? Is this patient on any meds to elevate the B/P? Are they still having pulmonary edema?

    Yes a patient can still have a decreased cardiac output even with the IABP if there was extensive damage to the myocardium...the IABP helps the heart rest and heal but the damage is done.

    My question is does this patient still have ineffective tissue perfusion now that they have had their PCI....the blockage is gone correct? Could they have ineffective tissue perfusion related to the poor EF? The balloon pump in the femoral artery to the affected extremity. Are the still having chest pain after the procedure? Could poor perfusion be caused from a poor EF?

    I am guessing that this patient coded, somewhere along the line, from a 100% occluded LAD was intubated. They suffered a massive MI went to cath lab had a PCI.....despite intervention the remained unstable and in cardiogenic shock a balloon pump was inserted and the patient transferred to ICU. I will bet he has a foley and sometimes if a male has an enlarged prostate it is difficult to pass they foley and if there is some trauma upon insertion that can lead to some bleeding around the meatus. OR they are hypercoagulated due to the procedure and IABP and need their coags rechecked. Knowledge deficit can be the patient and the family. Their loved one is critically ill...their lives have changed forever.

    so tell me about your patient.....what is a priority for this patient. http://allnurses.com/nursing-student...an-820899.html
    Last edit by Esme12 on Mar 14, '13
    pmabraham likes this.
  5. 0
    Since I have failed my ICU paper, I realized I am not going to be a nurse. If I cannot even pass a care plan or know how to properly diagnosed my patient, how can I be a good nurse? I thank you for helping me out but I guess I just don't get it. Thank you very much.
  6. 0
    What did you miss? Where in the process are you going off course?

    Care plans aren't that bad.....many students start off with the medical diagnosis and work backward or pick a diagnosis then try to fit the patient into it.

    These can help you know and follow what information is important....thank you daytonite...
    critical thinking flow sheet for nursing students

    student clinical report sheet for one patient


    You are just learning......what semester are you?

    TGell me the assessment of this patient and I can break it down for you...maybe help you see what you are missing.
  7. 0
    Hi Esme12,

    I'm in 3rd semester right now. Patient is 51 year old male came into ER c/o of chest pain starting an hour ago that woke him up from bed. He c/o of blurry vision and sob. Patient was given asa and ntg by ems on the way to the hospital. 2 ntg were given prior to arrival by ems. Pain was located in central chest and radiated to the right arm. MI suspected due to EKG showing tachycardia and ST elevation and increasing cardiac markers such as CK-MB and Troponin. When confirmed patient is having a STEMI due to anterior MI, patient was send into cath lab and found the LAD was 100% occluded. Ecchocardiogram also showed patient has an EF<15 and CO of 1.5L. Patient underwent an emergent PCI and had two drug eluding stents placed in artery. An IABP was put in to assist patient with circulatory flow. Patient on 2nd EKG showed a new right bundle branch block with accelerated junctional rhythm. MD decided to have a transvenous pacemaker put in. 3rd EKG showed NSR. Patient was sent back to cath lab to adjust IABP becasue it was kinking. Patient had flash pulmonary edema due to myocardial trauma but was resolved with diuretic. Patient is closely monitored in ICU due to post MI and having an IABP and transvenous pacemaker put in. Plan is to wean patient off IABP and removal of pacemaker once patient is stable.

    Neuro:
    GSC 9 with sedation. Able to follow command. Alert and able to nod or shake head when nurse asked simple questions. PERRLA, move all extremities.

    CV: cap refill is <3 secs. No pedal pulses palpated bilaterally but heard on doppler. Radial pulses are moderate. No JVD present.

    Pain: FLACC 0, monitoring chest pain

    GI: NPO. NG tube on low cont. suction. Coffee ground residual <25ml was noted in suction container during shift. Positive bowl sound in all 4 quads. Normal bowel sound and soft nontender abd.

    Genitourinary: Foley cath. Adequate UO -dark yellow and cloudy; bloody drainage around penis. 240cc UO

    Resp.: mechanically vent. at rate of 20 bpm. Auscultation revealed rhonchi bilaterally and diminished bases. Despite mechnical vent, patient's O2 continously dropped.

    Integ: pale skin but warm and dry. Surgical sites are clean and dry. No inflammation noted. Denied pain when palpated area around surgical sites. No swelling noted.

    Musculoskeletal: Bed rest. Lower extremities must by lay flat due to femoral arteries puncture sites for cath and pacemaker insertion. Able to move upper extremities. Bilateral equal strength. Normal strength and tone and no CVA tenderness.

    v/s:
    time : BP HR RR Temp. SpO2
    1200 112/69 74 20 98.3 100
    1300 109/72 70 20 97
    1400 94/71 70 20 97
    1500 81/52 72 20 94


    When I mentioned that patient pp are narrowing she told me that they are trying to wean pt off levophed and he also had alot of secretion and his HOB was at 0 degree. So in order to increase O2 they put him in reversed trendelenberg.

    His mech vent is set at
    FiO2 70% rate 20 Pressure support 15 PEEP 30/10 Mode pressure control vent

    Type of airway ET tube size of airway 7.5

    His ABG results

    pH: 7.19 pO2: 71.3 pCO2: 41.2 HCO3: 15.4 BE: -12.2 O2 sat: 88

    For this I said he was in uncompensated metabolic acidosis



    His lab is

    Normal Na+ and Cl
    CO2 is 19 low
    BUN 25 high
    Normal Creatinin
    glucose 358 high
    Albumin 3.2 low
    PTT is 22.4 low
    CPK 1332 high
    Troponin 29 high
  8. 0
    My instructor emailed me that basically all my points deducted were in the care planning section. I'm trying to study for my second exam but basically my mind is on this paper now and can't seem to concentrate
  9. 0
    Study for your test.....when do you take it?
  10. 0
    This coming wednesday. I'm meeting with my instructor after the exam to talk about the paper. I'm so afraid right now because if I don't pass the icu paper, I'm out of the nursing program. I have one last chance to resubmit it.
  11. 0
    Quote from ctran
    Hi Esme12,

    Patient is 51 year old male came into ER c/o of chest pain starting an hour ago that woke him up from bed. He c/o of blurry vision and sob. Patient was given asa and ntg by ems on the way to the hospital. 2 ntg were given prior to arrival by ems. Pain was located in central chest and radiated to the right arm. MI suspected due to EKG showing tachycardia and ST elevation and increasing cardiac markers such as CK-MB and Troponin. When confirmed patient is having a STEMI due to anterior MI, patient was send into cath lab and found the LAD was 100% occluded. Echocardiogram also showed patient has an EF<15 and CO of 1.5L. Patient underwent an emergent PCI and had two drug eluding stents placed in artery. An IABP was put in to assist patient with circulatory flow. Patient on 2nd EKG showed a new right bundle branch block with accelerated junctional rhythm. MD decided to have a transvenous pacemaker put in. 3rd EKG showed NSR. Patient was sent back to cath lab to adjust IABP becasue it was kinking. Patient had flash pulmonary edema due to myocardial trauma but was resolved with diuretic. Patient is closely monitored in ICU due to post MI and having an IABP and transvenous pacemaker put in. Plan is to wean patient off IABP and removal of pacemaker once patient is stable.

    Neuro:
    GSC 9 with sedation. Able to follow command. Alert and able to nod or shake head when nurse asked simple questions. PERRLA, move all extremities.
    CV: cap refill is <3 secs. No pedal pulses palpated bilaterally but heard on doppler. Radial pulses are moderate. No JVD present.
    Pain: FLACC 0, monitoring chest pain
    GI: NPO. NG tube on low cont. suction. Coffee ground residual <25ml was noted in suction container during shift. Positive bowl sound in all 4 quads. Normal bowel sound and soft nontender abd.
    Genitourinary: Foley cath. Adequate UO -dark yellow and cloudy; bloody drainage around penis. 240cc UO
    Resp.: mechanically vent. at rate of 20 bpm. Auscultation revealed rhonchi bilaterally and diminished bases. Despite mechnical vent, patient's O2 continously dropped.
    Integ: pale skin but warm and dry. Surgical sites are clean and dry. No inflammation noted. Denied pain when palpated area around surgical sites. No swelling noted.
    Musculoskeletal: Bed rest. Lower extremities must by lay flat due to femoral arteries puncture sites for cath and pacemaker insertion. Able to move upper extremities. Bilateral equal strength. Normal strength and tone and no CVA tenderness.

    v/s: Is this augmented (IABP pressure?)
    time : BP HR RR SpO2
    1200 112/69 74 20 100
    1300 109/72 70 20 97
    1400 94/71, 70, 20, 97
    1500 81/52, 72, 20, 94


    When I mentioned that patient pp are narrowing she told me that they are trying to wean pt off levophed and he also had alot of secretion and his HOB was at 0 degree. So in order to increase O2 they put him in reversed trendelenberg.

    His mech vent is set at
    FiO2 70% rate 20 Pressure support 15 PEEP 30/10 Mode pressure control vent (What was his title volume?)

    Type of airway ET tube size of airway 7.5

    His ABG results
    pH: 7.19 pO2: 71.3 pCO2: 41.2 HCO3: 15.4 BE: -12.2 O2 sat: 88
    For this I said he was in uncompensated metabolic acidosis

    His lab is

    Normal Na+ and Cl
    CO2 is 19 low
    BUN 25 high

    Normal Creatinin
    glucose 358 high
    Albumin 3.2 low
    PTT is 22.4 low
    CPK 1332 high
    Troponin 29 high
    Another question......What meds is this patient on? Did they have a PA line (swan ganz)?

    I have highlighted important information.

    Now, looking at what I highlighted......what do you think think patient needs....forget about the NANDA I diagnosis....what do you think they NEED. What is important? What is alarming about this information
    Last edit by Esme12 on Mar 22, '13


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