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altered cardiac function?

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I have a pt that had a mitral valve replacement back in the 80s. He takes coumadin at home, but the last time he had an INR was December. Of last year. =o

He comes in the hospital feeling weak, having tarry stools for at least 2 months.

His INR on admit was 5.6 and Hgb 4.5. Yikes.

The day I took care of him his INR was 1.7, still subtherapeutic. He is on heparin drip and coumadin. I found out he is on Heparin to help bridge him to just coumadin. Ok, I get all this.

Now, I was thinking of altered cardiac function r/t subtherapeutic INR and MVR. Would it rather be a risk for thrombus...? I'm just not sure how to say what I want to say, which is - he is at risk for a clot since his INR is not up to par yet.

I'm just having a brain block right now I think. -_-

LightMyFire

Has 3+ years experience.

What does INR affect, cardiac function or thrombus risk? Start there. Good luck!

Well, I'd venture to say thrombus? Ok, wait...Thrombus forming on mechanical valve and it doesn't work properly, there fore decreasing cardiac output?

And then there is the risk for stroke if said clot broke off?

Maybe?:yes:

LightMyFire

Has 3+ years experience.

Well, I'd venture to say thrombus? Ok, wait...Thrombus forming on mechanical valve and it doesn't work properly, there fore decreasing cardiac output?

And then there is the risk for stroke if said clot broke off?

Maybe?:yes:

Yes, INR affects thrombus risk. But does your patient have evidence (S&S) of altered cardiac output? The output is most likely fine (excluding other causes of altered cardiac output) but the defect causes an increased risk of clot formation. I might be leaning more toward perfusion risk. Sorry, I can't remember the NANDA dx but there are probably more than one you could choose from depending on your assessment data. HTH!

Yes it does! I know what I want to say, and in this case it is the risk for clots but wording it in Nanda is hard, I turned this in and will see what feedback I get!

As always, I appreciate the help here! =]

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

He comes in the hospital feeling weak, having tarry stools for at least 2 months.

His INR on admit was 5.6 and Hgb 4.5. Yikes

Now tell me why is this gentleman's cardiac output would be altered? Could it be a volume issue? Not enough fuel in the tank? Think......preload = pressure inside the heart during diastole (resting phase)

-starling curve. to a point, the more volume sitting in a chamber, the better a heart works

afterload = pressure the heart has to overcome to squirt blood out of the ventricle

-anything that causes resistance. from a malfunctioning valve to tight arteries to standing on your head.

Gross analogy, but works for me....

Thing about flushing a toilet......

you flush, and then flush again right away......nothing happens right? This is because the tank doesn't have time to fill....PRELOAD is decreased in the tank.

What if the toilet is plugged up? When you flush, it backs up....this is too much afterload.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Lets start back at the beginning.....

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.

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.

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 from our Daytonite

  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)

  1. 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 careplan of yours will lie in the abnormal data (symptoms) that you collected during your assessment of this patient......in 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.

Another member GrnTea say this best......

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.

Esme12, ASN, BSN, RN

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma. Has 41 years experience.

Well, I'd venture to say thrombus? Ok, wait...Thrombus forming on mechanical valve and it doesn't work properly, there fore decreasing cardiac output?

And then there is the risk for stroke if said clot broke off?

Maybe?:yes:

If the valve is mechanical odds are with an INR of 5.6

his blood is pretty thin and he has been bleeding. SO......if the blood id too thin is there a clot risk? Is there a bleeding risk? Tarry stools HGB of 4!!!!!!!!!!!!!!!!!!!!!!!! What is this patients greatest concern?

Sun0408, ASN, RN

Specializes in Trauma Surgical ICU. Has 4 years experience.

🙏👏 welcome back esme!! You must be feeling better, I'm seeing longer posts from you😉 hope you continue to recover!!

ixchel

Specializes in critical care.

Now tell me why is this gentleman's cardiac output would be altered? Could it be a volume issue? Not enough fuel in the tank? Think......preload = pressure inside the heart during diastole (resting phase)

-starling curve. to a point, the more volume sitting in a chamber, the better a heart works

afterload = pressure the heart has to overcome to squirt blood out of the ventricle

-anything that causes resistance. from a malfunctioning valve to tight arteries to standing on your head.

Gross analogy, but works for me....

Thing about flushing a toilet......

you flush, and then flush again right away......nothing happens right? This is because the tank doesn't have time to fill....PRELOAD is decreased in the tank.

What if the toilet is plugged up? When you flush, it backs up....this is too much afterload.

Best analogy for this ever!

ixchel

Specializes in critical care.

Love seeing you in the student forum again, Esme!

LightMyFire

Has 3+ years experience.

Loving the detailed help from the veteran nurses! It's hard to think as a student these days. With a little experience you start to just form these ideas without really knowing how or why. You just know. I wish I could explain my thought process so well!