Is my pt in heart failure??

[aimes.k559]

I'm a first year nursing student on my first clinical placement and I'm worried my pt is in heart failure (my clinical instructor tells me this isn't the case). My pt has a history of CABG, ischemic heart disease, hypertension and Paroxysmal atrial fibrillation, also rushed to hospital last month with chest pain and tachycardia. On assessment I noted pitting odema stage 2 around feet and ankles, and his feet were much cooler than his legs, pale even slightly bluish. He has an intermittent cough and regular SOB brought on without any exertion. He has an inhaler for a wheeze he apparently gets from time to time (I'm thinking pulmonary edema or cardiac asthma?) because he told me he's never needed an inhaler in his life till he came to the rest home. Am I being paranoid? I'm really worried about him. My clinical tutor told me not to write anything cardiac related as a priority, but from what I've been researching it sounds like he's in heart failure! any thoughts would be much appreciated!!

[ChristineN, BSN, RN]

How were his posterior tib and Dorsalis pulses? What was his current heart rhythm. What does sitting for extended periods in a wheel chair do for his lower extremity edema?

Sounds like the OP is in LTC so they may not have access to the current heart rhythm

[BostonFNP, APRN]

Sounds like the OP is in LTC so they may not have access to the current heart rhythm

I was just think more along the time of what she auscultated for a rate/rhythm with the patient's history and cardiac output :)

[StudentOfHealing]

I was just think more along the time of what she auscultated for a rate/rhythm with the patient's history and cardiac output :)

When 4 out of my 4 oatients have afib and I auscultate their apical pulse I do so more than anything for the character/quality. It's so hard to get a rate. I just print a tele tracing and count that way. I've always wondered - (and maybe this is an elementary question but I AM but a novice nurse) - The reading the tele monitor gives is not accurate right (when they have afib)? I was taught to print out a tracing and count my QRS complexes to be 100% sure of ventricular rate and assess for any RVR.

Sorry to take this off topic.

[mrsboots87]

He has had a stroke which is why he is in the rest home now. I'm guessing it was possibly the atrial fibrillation that caused that? Anyway he has L) sided hemiparesis. He is allergic to ACE inhibitors but takes a B-blocker and a anti-arrhythmic. He has good fluid and food intake. Good sensation on right side, no pain apart from pain in his left hip he says is from sitting in wheelchair for long periods. His SOB doesn't bother him much it's like he's used to it, but he says it can get really bad, he gets a wheeze and he has an inhaler for that. My 3 nursing Dxs were going to be L) hip pain r/t extended periods in wheelchair, Dyspnea r/t decreased cardiac output and insuffient peripheral circulation r/t decreased cardiac output as evidenced by edema

You are close but not quite there. Your 3 Dx will not be one sentence. They will be 3 separate ones. Also, hip pain is subjective and is not a nursing diagnoses, it is what should be placed in the AEB part of your diagnoses. You never answered if you are using a NANDA nursing diagnoses book. You will fail this part of your care plan if you are not using diagnoses from NANDA. When the patient stated he had hip pain, did you check his ROM? Sensation in that extremity? Skin coloration? Musculoskeletal formation of the area? The idea is not to note that he had hip pain, but look for what is causing the hip pain so you can intervene appropriately. For basic pain one might give pain meds. But if the cause of the pain is not known, then pain meds are equivalent to putting a bandage on a deep laceration. What you need to be writing fr your care plan should look like this (note I am using an example that is intentionally not specific to your patient) "Excess fluid volume r/t compromised regulatory mechanism AEB peripheral edema and decreased hemoglobin and hematocrit". You can use excess fluid volume for your patient but your etiology and S/Sx will be different. It sounds like your patient has impaired physical mobility. Most likely due to his hemiperesis. This is manifested in ???

Go get a good care plan writing book with NANDA approved nursing diagnoses in it like yesterday. This will save you TONS of time and earache when writing your care plans.

[mrsboots87]

Also what did you do to intervene for his hip pain? Did you show him ROM exercises he could perform in his wheelchair? Or maybe provide a pressure reducing device for him to sit on? Or advise him to shift his weight slightly periodically throughout the day? I'm sure you have learned that the basic timeframe for repositioning immobile patients is q2h or sooner. It is the same for a wheelchair bound patient. They need repositioning and pressure relieving pillows for their chairs or they start to get skin and musculoskeletal pain and even rashes and pressure ulcers. Obviously being your frat clinical it will take time to start to think about these things on the spot but you will get there. Them you will start a new semester after feeling confident in you clinical abilities of the first and you start all over again with learning what to do.

[aimes.k559]

I couldn't palpate the pedal pulses or his apical pulse. My clinical instructor told me that was to be expected, radial pulse was weak and very irregular. I did put in my care plan to avoid sitting for long periods of time with legs in dependant position because of the edema

[aimes.k559]

I do have a NANDA diagnoses book, but I'm not allowed to use the more complex diagnoses because it's an aged care setting and apparently the NANDA diagnoses are too medical sounding for this environment as caregivers must be able to read the care plans and understand them.

[LadyFree28, BSN, LPN, RN]

I do have a NANDA diagnoses book, but I'm not allowed to use the more complex diagnoses because it's an aged care setting and apparently the NANDA diagnoses are too medical sounding for this environment as caregivers must be able to read the care plans and understand them.

That is ridiculous; how are you going to formulate a nursing diagnosis by NOT using the book?

NANDA has NURSING diagnoses; not medical ones.

Crack open the book, see what matches up per your assessment, and go from there.

[ChristineN, BSN, RN]

I couldn't palpate the pedal pulses or his apical pulse. My clinical instructor told me that was to be expected, radial pulse was weak and very irregular. I did put in my care plan to avoid sitting for long periods of time with legs in dependant position because of the edema

No one can palpate an apical pulse. You assess the apical pulse, which is the pulse you assess directly from the heart itself, by using a stethoscope. You should have been able to hear an apical pulse and determine if it sounded regular or irregular.

[mrsboots87]

I do have a NANDA diagnoses book, but I'm not allowed to use the more complex diagnoses because it's an aged care setting and apparently the NANDA diagnoses are too medical sounding for this environment as caregivers must be able to read the care plans and understand them.

That's nuts that they don't want you to use the nursing diagnoses book. Especially in your first clinical rotation. And many of the diagnoses are not even "complicated". "Impaired physical mobility" is def not a complicated term for a caregiver to follow. And Caregivers don't generally see the nursing notes nless they are a nurse or higher up in the care of the patient. Their reasoning is not sound, especially because if you were to see the care plan created for that patient in that facility, the nurse who made it didn't dumb it down for the caregivers. They use NANDA diagnoses. Just all around weird.

[VANurse2010]

No one can palpate an apical pulse. You assess the apical pulse, which is the pulse you assess directly from the heart itself, by using a stethoscope. You should have been able to hear an apical pulse and determine if it sounded regular or irregular.

You are correct, but actually you *can* palpate an apical pulse on some thin people.