Help with Nursing Care Plan

[aguacates11]

I have to come up with three priority nursing dx for a pt who presented with Chest pain. Prior medical hx of microvasc. angina, POT syndrome, chronic fatigue, fibromyalgia, IBS, celiac.

Current assessment data as follows, arranged in Gordon's functional health patterns:

Health Perception-Health management.

views health as poor. sees an acupuncturist for pain control. non-drinker and non-smoker. Interest is shown in a cardiac rehabilitation program. full-code status. multiple chronic conditions including Fibromyalgia, POT Syndrome, and the related pain and depression. expresses concern at the lack of continuity of nursing care during her hospital stay.

Nutritional-Metabolic

26 lb weight gain in the past 6-8 months. A recent endoscopy revealed an increase in eosinophils in throat due to multiple severe allergies according to patient report. 75% of tray consumed on average each meal. refuses to comply with the cardiac diet requested; observed eating outside food each time room was entered . multiple food allergies, follows gluten free diet. Skin integrity appeared intact. Skin appeared free of lesions, warm, dry, color normal for ethnicity. Patient had Port-a-cath in central line, dressing intact, no discharge visible. A clonidine HCl patch adhered to upper left arm. Oral Temperature measured 37.1, weight measured 109 kg with height measuring 5 feet 7 inches.

Elimination

history of IBS and Celiac. Celiac sprue were visualized on past colonoscopy. Pt has not had bowel movement since Thursday, . has bowel movement at home due to Calm (brandname) magnesium supplement. not taken it during hospitalization. Urine output 600 ml over 6hr period. Urine appears yellow in color, free of sediment, and lacks strong odor. concern about "urine being tested" prior to discharge.

Activity-Exercise

frustration with her constant fatigue. uses 3 pillows each night in recliner to sleep. POT syndrome and fibromyalgia prevent from getting exercise, performs activities of daily living at home "okay". currently takes atenolol. hypercholesteremia. interest in cardiac rehabilitation program. Breath sounds auscultated bilaterally in upper and lower lobes. Heart sounds auscultated, s1 and s2 present. Capillary refill appears less than 2 seconds, sensation and mobility observed as intact. Possible swelling in right lower extremity noted. Non-pitting +2 edema observed around ankle and dorsal surface of foot. BP observed 99-112/58. Respirations observed at 14 breaths per minute, with a pulse rate of 85 beats per minute. Oxygen saturation appears sufficient at 95% on room air. troponins less than 0.03, ECG showed ST wave elevation on admission, myocardial perfusion scans show adequate perfusion with EF of 54%. No signs of coronary artery disease .

Sleep-Rest

Recliner used nightly for sleeping. Patient reports frequent naps that do nothing to relieve exhaustion or renew energy.

Cognitive-Perceptual

chronic pain at best 6/10, at worst 9/10. recently started taking pregabalin (Lyrica) for fibromyalgia. alert and oriented times three prior to receiving meds, post medication, oriented to place and person, but not time and expresses confusion over the day and order of events of hospitalization. Patient reports vision is decreasing, pupils are staying dilated and cannot read as well. expresses frustration with memory functions. takes venlafaxine, clonidine HCl, and fentanyl for POT/fibromyalgia pain. Pupils are round, reactive to light and accommodation.

Self-Perception-Self-Concept

receives disability, and views personal health as poor. recently had a positive nasal swab for MRSA. feelings of limitation due to her pain from her chronic conditions. appears distracted with poor eye contact.

Role-Relationship

Patient expresses anxiety about recent MRSA diagnosis, verbalizes fears that daughter will not let pt see the grandchildren, believes daughter to be unreasonable about fears of contagion. Husband appeared interested in program of care, spent time in room reading materials on MRSA. He verbalized that he hoped enough information would satisfy their daughter.

Sexuality-Reproductive

married for 24 years, gravida 2 para 2. post-menopausal, no contraception used. Patient also verbalizes lack of sexual desire due to polypharmacy.

Coping-Stress

in process of moving from home to an apartment. husband and daughter are primary sources of emotional support. appears tearful and distraught each time room is entered. fears about lack of positive findings on her cardiac function tests. just wants to know why she is having so much pain. tangled self in IV/PCA lines, became tearful. uses multiple medications to cope with fear and anxiety, and requests ativan/benadryl together. takes venlafaxine in addition to lorazepam, Benadryl, clonidine HCl, pregabalin, and fentanyl.

Value-Belief

seeks acupuncture care on a regular basis. utilized the hospital chaplain during recent hospitalization. attends church at home when health permits. does not plan much for the future because believes health status to be precarious.

Okay, sorry for the funky format. So that is all my assessment data.

pt was being discharged, chest pain was attributed by doctors to be from the microvasc. angina or the pot syndrome, not MI

So, I've pulled together

1. Activity intolerance r/t chronic pain AEB Pt stating,"my pain and fatigue really limit what

I can do"

2. Chonic pain r/t disease state AEB pt reporting " I came in when accupuncture wasn't working anymore"

3. Imbalanced nutrition: more than body requirements r/t intake greater than metabolic need AEB BMI greater than 35.

Am I on the right track? I feel kind of confused by the presenting chest pain that was attributed to her chronic conditions by the physician. All the heart function tests showed her heart function is within normal limits, so I didn't go with cardiac output, decreased, her breathing was fine, really her anxiety was another big issue, but I was trying to choose physiological rather than psychosocial. Okay, any other thoughts will be much appreciated!

Thanks in advance, NS