Care Plan help... CHF and Altered Mental Status....

LVAD RN · Mar 13, 2009

If she is on Aspiration precautions then you could use Aspiration, risk for r/t reduced level of consciousness or impaired swallowing if she had that

Psychosocial you could use the one you have Impaired verbal communication r/t language barrier you could also use Risk for social isolation r/t language barrier

Risk for decreased cardiac output r/t altered heart rate as evidenced by tachycardia Pulse 102

OR

Decreased cardiac output r/t altered contractility AEB crackles

Hope this helps.

jayebird28 · Mar 13, 2009

Yes, snydayz, you helped out alot. I think that I may be overthinking this care plan and trying to make it more difficult than it actually is. I have a tough clinical instructor so i am trying to make sure I have everything covered!

Daytonite, BSN, RN · Mar 14, 2009

first of all, there is no room for panic. you have plenty of information to do a care plan for this patient. sit down and think this through logically. chf is one of the most common reasons that people are admitted to the hospital. a care plan is the determination of the patient's nursing problems and developing nursing interventions for them. we use the nursing process which is our problem solving tool to help us. it has 5 steps and should be followed in the sequence that they occur. in writing a care plan you will spend most of your time with steps 1 and 3 of the nursing process--that is, if you want to do this care plan rationally and correctly.

step 1 assessment - assessment consists of:

a health history (review of systems)
performing a physical exam - did the patient have all the signs and symptoms of chf that the textbook says a patient with chf has?
assessing their adls (at minimum: bathing, dressing, mobility, eating, toileting, and grooming) - if she was on "fall precautions" did she have mobility problems? use any assistive devices?
reviewing the pathophysiology, signs and symptoms and complications of their medical condition - first look up chf and what is going on when a patient has chf. it will help explain why some of the things were ordered and done for this patient (the foley catheter, i&os and daily weights). also look up cad and how it may contribute to her development of chf. i also noticed that she had a b/p of 145/92. that is her cad. she has a history of hypokalemia and her current k+ while being within normal limits is at the low end of normal (3.5-5.0 and she is 3.6).
reviewing the signs, symptoms and side effects of the medications they are taking - her medications don't completely match her list of diseases. the prilosec is given for gerd, ulcers or gastritis, oversecretion of gastric secretions or prevention of these conditions. namenda is given for alzheimer's disease (that wasn't mentioned in her history!). zoloft is an ssri antidepressant which means she has been on it for some time because it takes time for it to build up in the system to be affective. the lasix is obviously being given for her chf; the vasotec is for chf and left ventricular failure. someone her age should be on a calcium replacement. why is she getting something for pain? did she have pain (other than chest pain she might have had on admission)?

this is a medical treatment: a foley catheter. it was inserted to monitor her output unless she has incontinence problems. chf patients are given diuretics and oxygen when they are admitted to get the fluid out of their systems and make sure they are getting oxygenated. they are retaining fluid, their lungs are loaded with fluid and the fluid in their lungs is interfering with the exchange of oxygen and carbon dioxide and in some situations it becomes life threatening.

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - all nursing diagnoses begin by us collecting evidence of their existence and that is what we are doing when we assess. we are looking for what isn't normal. here is what you posted about this patient that isn't normal:

crackles heard in left lung
p-102
bp-145/92
no pedal pulses
edema 1+ possibly 2+
i&o on 3/10 were: i: 100; o: 1300
doesn't know where she is
it was very tough communicating with her because of her mental status
she is spanish speaking
labs:
- bun 26
- neutrophils 36.46
- lymphocytes 49.22
- ptt 22.8

step #2 determination of the patient's problem(s)/nursing diagnosis part 2 - match your abnormal assessment data to likely nursing diagnoses, decide on the nursing diagnoses to use - you should be using a nursing diagnosis reference book or a care plan that has this information about every nursing diagnosis: its definition, related factors (causes) and defining characteristics (symptoms). these can also be found in the appendix of taber's cyclopedic medical dictionary. match your list of evidence with defining characteristics of nursing diagnoses that will apply to your patient. this is what i would diagnose.

ineffective airway clearance r/t secretions in alveoli aeb crackles in the left lung
decreased cardiac output r/t impaired heart function aeb tachycardia (rate of 102), elevated b/p (145/92) and 1+ to 2+ peripheral edema
excess fluid volume r/t impaired secretion of sodium and water aeb crackles in left lung and 1+ to 2+ peripheral edema
disturbed sensory perception, visual r/t altered sensory input aeb legal blindness and disorientation to place
acute confusion r/t memory impairment aeb disorientation to place and difficulty communicating with patient [the communication difficulties need to be stated more specifically]
impaired verbal communication r/t speaks/understands different primary language aeb communication difficulties [needs to be specified that translators were required]
risk for falls r/t age, altered mental status, impaired vision, and taking antidepressants and diuretics

------------------------------

decreased cardiac output r/t ?

get into the habit of referring to a nursing diagnosis reference. this diagnosis is a physiologic diagnosis that covers everything that can go physically wrong with the heart including oxygenation issues. look at the defining characteristics for this diagnosis and you will see all the different symptoms of all the different heart failures. the

r/t

part of every nursing diagnostic statement is what has caused the nursing diagnosis (the problem) in nice generic medical language. why did she get chf? her pump (heart) failed her. that's the easy way of putting it since you are a first semester student. it is actually more complicated than that but we can leave the more complicated reason for another semester. i actually put "impaired heart function" on my diagnosis for this above. if you want to read about chf and what really happened--go for it. the aeb information is the evidence that proves the

decreased cardiac output

exists. that would be the tachycardia, hypertension and peripheral edema.

activity intolerance r/t bedrest or i can put r/t imbalance between oxygen supply and demand.

i did not diagnosis this because i didn't see you list any evidence that the patient had this.

activity intolerance

is fatigue brought on by activity and the patient must have altered heart

and

respiratory rates at the least. they usually also have elevated b/ps and ekg changes if they are being monitored. sometimes they get hypoxic and almost always get short of breath. they get so bad with activity that the activity has to be stopped and the patient has to sit down. you had none of that evidence so i have no idea why you are diagnosing the patient with this.

impaired verbal communication r/t inability to speak language of caregiver and /or altered mental status.

i agree that "

inability to speak language of caregiver

" is an appropriate related factor for this diagnosis, but i do not get where an "

altered mental status

" applies. you never really described this altered mental status of hers and never really stated what was wrong with her speech as a result of her altered mental status. does she mumble, stutter, repeat everything because she forgot she just said it, slur her words. being disoriented isn't enough. this is about using language to communicate. you wouldn't say "

and/or

" because it implies that you aren't sure and that is very unscientific. i think of ozzie osborne when i think of this diagnosis. can anyone beside his family understand his mumbling?

Daytonite, BSN, RN · Mar 14, 2009

oh, step #3 is planning (write measurable goals/outcomes and nursing interventions). they are based upon your evidence (those aeb items) which is why they are so important.

allnurses Guide · Mar 14, 2009

Reduced CO -> impaired perfusion -> altered mental state?

Daytonite, BSN, RN · Mar 14, 2009

Reduced CO -> impaired perfusion -> altered mental state?

Is this a question for the OP?

jayebird28 · Mar 14, 2009

You never cease to amaze me. I have read several of your replies to other students and you are always so helpful! Thank you, thank you, thank you. It's nice to have someone looking out for the underdogs!

jayebird28 · Mar 17, 2009

She is taking the Namenda for the dementia.

RochesterRN-BSN, BSN, RN · Mar 17, 2009

Was her urine checked.... 88 YO with MS changes......her dementia progressing vs. a UTI. And the low respiratory rate is concerning...the narcotic?

We see a lot of older folks in psych and we end up sending them back to medical as it turns out to be delerium which is medical not psych so with all her medical you have to be careful and not assume its the dementia-- delerium and dementia are not the same. Just a few things think about--I see you got lots for your actual nursing Dx so I figured I would give you some other things to think about......though this lady seems okay many with CHF also have COPD and the high CO2 is the cause of the MS changes......just for future reference.

Good luck and hope you do well. God I hated those stupid care plans!!! lol