Need help with cardiac diagnoses...Please!!!

[liverluv]

I need some serious help!!! I've been working on my diagnosis for my process paper and am still struggling. My patient was admitted b/c her ICD was continually firing, she was experiencing SOB and angina unrelieved by nitro. The thing is, when I assessed her, she was going to be dc'd later that day, so her symptoms had all subsided. Her EKG showed a-fib w/ sinus bradycardia when I checked it. (Her PMD includes CHF, atherosclerosis, HTN, V-tach, A-fib, Dilated Cardiomyopathy, MI, Pulmonary Edema, amongst several others; her medical diagnosis was arrhythmias) This is what I have right now:

NURSING DIAGNOSES ***In priority order***

1. Decreased Cardiac Output r/t Cardiac Arrhythmias AEB Atrial Fibrillation on EKG

2. Ineffective Breathing pattern r/t Acute Chest Pain AEB Dyspnea

3. Acute Chest Pain r/t Atherosclerosis and Coronary Spasm AEB Substernal, Aching, Level 5 Pain

4. Activity Intolerance r/t Imbalance Between O2 Supply and Demand AEB Verbal Report of Fatigue and Weakness

5. Deficient Knowledge: Performance of ICD r/t Lack of Information AEB Verbalized Knowledge Deficit

Do I still keep all of the diagnoses even though she was not currently experiencing the symptoms? If so, does ineffective breathing pattern take priority over decreased cardiac output (bc of ABC's)? I also came up with

Powerlessness r/t CHF AEB expression of having no control over situation or outcome

also, but she came in b/c her ICD was excessively firing---not b/c of CHF--CHF is in her hx. though.

Should I get rid of the ineffective breathing and acute chest pain b/c she was not experiencing either when I assessed her?

Super confused and need some much appreciated help!! Any suggestions?

[Daytonite, BSN, RN]

3. acute chest pain r/t atherosclerosis and coronary spasm aeb substernal, aching, level 5 pain

i would be hesitant about using atherosclerosis as a related factor. atherosclerosis causes narrowing of the coronary arteries. is that what is causing the chest pain or is it the resulting ischemia? the related factors for pain are things that have caused injury. as for coronary spasm, what is actually spasming? how about saying something like

acute chest pain r/t myocardial ischemia and coronary artery spasm aeb substernal aching, level 5 pain

5. powerlessness r/t chf aeb expression of having no control over situation or outcome

chf is a medical diagnosis and cannot be used in diagnostic statements as a related factor. a person feels powerless because of the circumstances. so,

powerlessness r/t chronic weakening illness aeb expression of having no control over situation or outcome

your care plan is for a window in time. if you do not feel comfortable that these are actual problems for that window when you had the patient then turn them into anticipated problems. i'm looking at her history. with atherosclerosis, cardiomyopathy and a history of an mi, she has chest pain, dyspnea and activity intolerance to look forward to. about the only diagnosis i might change would be acute pain to risk for acute pain meaning angina. if activity brings on angina, however, it is an actual problem.

[liverluv]

wow! thanks so much for your help! a few more questions if you don't mind...how do these sound...

nursing diagnoses ***in priority order***

1. decreased cardiac output r/t cardiac arrhythmias aeb atrial fibrillation on ekg

does ineffective breathing take priority over decreased co (referring to abcs)?

2. ineffective breathing pattern r/t acute chest pain aeb dyspnea

is it ok to say r/t acute chest pain even though her pain has gone away?

3. acute chest pain r/t myocardial ischemia and coronary spasm aeb substernal, aching, level 5 pain

what could show proof of myocardial ischemia? is the pain enough evidence to show that?

4. activity intolerance r/t imbalance between o2 supply and demand aeb verbal report of fatigue and weakness

5. deficient knowledge: performance of icd r/t lack of information aeb verbalized knowledge deficit

do you think i should kick one of the diagnoses out and use

powerlessness r/t chronic weakening illness aeb expression of having no control over situation or outcome

[Daytonite, BSN, RN]

1. decreased cardiac output r/t cardiac arrhythmias aeb atrial fibrillation on ekg

does ineffective breathing take priority over decreased co (referring to abcs)?

decreased cardiac output

comes first because it is addressing hypoxia, an oxygenation issue. while breathing oxygen is important, the oxygen isn't getting anywhere in the body without being transported there by the circulatory system, so if the heart stops working the body dies. heart cells will die faster from lack of oxygen (infarct) than lung cells will, so they get priority for care.

decreased cardiac output

is about oxygen perfusion to the cells of the heart tissues. symptoms of atrial fib (beside ekg documented evidence) includes palpitations and a sensation of a racing, uncomfortable, irregular heartbeat, weakness, lightheadedness, confusion, shortness of breath and chest pain.

2. ineffective breathing pattern r/t acute chest pain aeb dyspnea

is it ok to say r/t acute chest pain even though her pain has gone away?

yes. chest pain is one of the causes of inadequate ventilation (this problem). see the related factors on this web page

[color=#3366ff]ineffective breathing pattern

.

3. acute chest pain r/t myocardial ischemia and coronary spasm aeb substernal, aching, level 5 pain

what could show proof of myocardial ischemia? is the pain enough evidence to show that?

there may be no symptoms or there may be arrhythmias, fainting, angina, neck or jaw pain, arm pain, clammy skin, shortness of breath, nausea and vomiting.

do you think i should kick one of the diagnoses out and use

powerlessness r/t chronic weakening illness aeb expression of having no control over situation or outcome (i changed some of the wording)

i thought all your diagnoses were fine including

powerlessness

. i would sequence them:

1. decreased cardiac output r/t cardiac arrhythmias aeb atrial fibrillation on ekg
   
   
2. ineffective breathing pattern r/t acute chest pain aeb dyspnea
   
   
3. acute chest pain r/t myocardial ischemia and coronary artery spasm aeb substernal aching, level 5 pain
   
   
4. activity intolerance r/t imbalance between o2 supply and demand aeb verbal report of fatigue and weakness
   
   
5. powerlessness r/t chronic illness aeb expression of having no control over situation or outcome
   
   
6. deficient knowledge: performance of icd r/t lack of information aeb verbalized knowledge deficit

see https://allnurses.com/forums/f50/help-care-plans-286986.html - assistance - help with care plans (in the general nursing student discussion forum) for information on how to write a care plan.

[liverluv]

I wanted to say thank you so much for your help. You have no idea how grateful I am! I noticed you help out a lot of other students in need and I think it's great--it is all very informative, but still understandable! Thank you again--you are very much appreciated!! :)

[Daytonite, BSN, RN]

Best wishes on your work with this paper.