Help with care plan

[smurfet]

I am needing help with nursing diagnosis for my care plan. My patient is 51, in good health. The only problems he has had is history of hypertension. He was admitted to the hospital after complaints of fatigue, pain in the lower legs, and fluttery feelings in his heart. He was diagnosed with Afib and a clot was found in his heart chamber. all of his CBC and electrolyte test are normal. His Ptt is 100 and INR 1.7. He is on Coumadin, Lovenox and Coreg. BP has been around 113/74 because of the medication. It was 145/95 when he was admitted to the hospital but has been reduced. Coumadin and Lovenox are new medications that he has just recently been put on because of the clot. Any help is appreciated

[donsterRN, ASN, BSN]

I can see a lot of teaching needs...

[Daytonite, BSN, RN]

organize your data and use the nursing process to help you.

step 1 assessment - collect data from medical record, do a physical assessment of the patient, assess adl's, look up information about your patient's medical diseases/conditions to learn about the signs and symptoms and pathophysiology

• new onset of atrial fibrillation - look up the signs, symptoms, pathophysiology and complications of this condition
  
• fluttery feelings in his heart
  
• clot was found in his heart chamber - symptom of af
  
• fatigue
  
• pain in the lower legs - possible complication of af - risk for dvt
  
• history of hypertension
  
• treatment/medications:
  • coumadin (new) - look up side effects
    
  • lovenox (new) - look up side effects
    
  • coreg - beta blocker given for hypertension

step #2 determination of the patient's problem(s)/nursing diagnosis part 1 - make a list of the abnormal assessment data - is the pain in his legs gone? how is the af being treated? has the coreg slowed the heart rate at all? it is interesting that for your patient with af you mention no heart rate. how is the af being controlled? the blood clot in his heart is a complication and a result of the atrial fib, so not only the clot, but the atrial fib would be addressed by the doctor.

• ptt is 100 (elevated)
  
• inr 1.7 (should be >3 for patients on anticoagulants)

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

• decreased cardiac output r/t altered electrical conduction aeb fluttery feelings in his heart [and any other symptoms of the af]
  
• ineffective tissue perfusion, peripheral r/t interrupted blood flow aeb pain in lower legs
  
• activity intolerance r/t imbalance between oxygen supply and demand aeb fatigue
  
• risk for injury r/t altered clotting factors

[smurfet]

Thank you so much. This is really helping me understand alot and about the full process.