confused about medical diagnosis (for care plan)

[sonja77]

i'm confused about my patient's medical diagnosis and what to write up for the care plan.

here's what was in the kardex under diagnosis:

- a-fib with rvr, syncope

- palpations, systolic atn, recent syncope

we have to write up either one or two medical diagnosis, depending on the patient's problems. i don't even know what to look up for my pt.

and does anybody know what rvr and atn stand for?

thanks!

[icugirl33]

hi,

RVR stans for rapid vebtricular rhytym, and ATN might stand for Acute tubular necrosis..

A good nursing dx might be Altered tissue perfusion related to rapid heart rates and loss of atrial kick as evidence by dizziness, fatigue, fluttering in their chest, ect...

The ATN occurs when the tubular cells of the kidneys don't get enough oxygen & begin to die. The systoli part of ATN means the pt is hypotensive, systolic bp lthat is really low. Maybe someone will come up with a good nsg dx related to the systolic atn.

Good luck

[BCzito]

syncope is fainting, you could make a nursing diagnosis of risk for injury due to syncope.

a-Fib is atrial fibrillation, nursing wise this could be an alteration in the heart as a pump, leading to slow ventricular filling and altered perfusion.

[sonja77]

i'm sorry, i think my first post was a bit unclear.

we have to write up a medical diagnosis, a little bit of research from the med/surg book. we have to look up the definition, pathophysiology, s/s and diagnosic tests.

i just don't know what to look up for my patient. the atrial fibrillation maybe? but wouldn't the medical diagnosis be cardiac dysrhythmia?

thanks for the abbreviations, they helped! :)

[sonja77]

and while i'm here, does anybody know what crppi means?

it should be a treatment or activity level, it said: begin crppi and advance as tolerated

thanks again!

[honeyb111]

We have to write up the medical diagnoses also - our instructors have told us to go with the first one listed as that is the patient's most current problem, the why they are in the hospital now. I would go with the A-fib with RVR (Rapid Ventricular Response) and syncope. It looks like the line below that (palpations etc...) are symptoms the patient was having at admit???

As for CRPPI, I have no idea and neither does my acronym finder. It's posted on this board somewhere but here's the addy for you - http://www.acronymfinder.com/ It's been a lifesaver with all these medical abbreviations.

Hope that helps you some!!!

Sharon

[neneRN, BSN, RN]

Your diagnosis will be the A-fib- should be easy to find the pathophys as this is a very common condition- some pts are in A-fib all the time- it becomes dangerous when its a rapid A-fib (aka A-fib with RVR), high risk for forming clots secondary to the blood pooling in the atria. Diagnostics will include a 12 lead EKG, cardiac enzymes (a heart beating that fast is going to be stressed a bit), PT/PTT with INR (again that high risk of clotting so you want to see where your pt is with their coags), CXR, and ECHO (there we go looking for clots again). Symptoms- think about how anyone would feel with a racing heart; lightheadedness, heart racing, SOB, chest pain, dizziness, palpitations. Pt may be given meds to slow heart rate- most often Cardizem IV, given as 1 or 2 boluses, followed by a drip. Sometimes they convert on their own, sometimes additional meds are needed, occasionally synchronized cardioversion. If they are not already on Coumadin with therapeutic levels, you may see the pt getting Heparin gtt. I know that's kind of a quick run through, but these are the key things to look up in your research. Good luck!

[sonja77]

thanks for everybody's responses, they helped quite a bit.

i went ahead and called my clinical instructor and she said to use cardiac dysrhythmia (atrial fibrillation) and syncope as the two medical diagnoses.

she also explained why this patient had so many diagnoses listed: she's a medicare pt., so in order to be reimbursed for everything, the hospital has to document everything