care plan for afib patient

[studentnursemaddy]

hello all, this is my first time using this site and I am hoping everyone can help. i am in my first semester of nursing school and this program is pretty tough and fast paced. i have no medical background which I am starting to feel is a huge disadvantage.

i am working on a care plan for my patient that was admitted to the hospital (a scheduled admit) for tikosyn administration because after having a cardio version and an ablation is still going into afib. this patient was actually in fairly good health and was less than 60 years old. the biggest issues i noticed with her are that upon coming out of afib she complains of headaches, and weakness and has increased blood pressure for a very short period of time. she complained to me that she was afraid to go back home and continue life as usual because she lives alone and has to cut wood for heat and be pretty active as she lives alone. i wanted to do my care plan on activity intolerance as i believe her fear of elevating her heart rate is keeping her from continuing about her regular activities. also while i was in the hospital i had her for 2 days before she was discharged. i made a brief intervention paper before i had her the last day and i came up with making her walk a few laps around the unit to elevate her heart a little and monitor it, and then i gave her education as well as with her cardiologist about remaining active and when to call the doctor for serious signs. i have no actual idea how to make this a care plan or what to even write. my school is kind of like a throw you to the wolves kind of program and i have dreamed of being a nurse my whole life. any help would be great i am also willing to give more information as well as other parts of my Gordons health patterns that i feel she has deficits in. thanks to all who comment

Maddy

[nursej22, MSN, RN]

Please check out Esme's answer on this thread; she provides a very clear, thorough explanation of nurse care planning.

https://allnurses.com/nursing-student-assistance/pt-priority-dx-1116436.html

But briefly, your plan of care should be based on your assessment of the patient, not on the medical diagnosis. Yes, the diagnosis may lead you toward some possible issues the patient may have, but it should be based foremost on patient needs.

You don't say much about your assessment, other than the patient's concerns, which is good. But other than activity intolerance, were there any other "abnormals" in her assessment? Labs, vitals, new meds, dietary restrictions, anticoagulants that could put her at risk for injury? You mentioned education and there is a nursing dx that goes with that...